PHILADELPHIA POLICE DEPARTMENT

COMPUTER ASSISTED DISPATCH (CAD) INFORMATION FORM

This form is to assist the City of Philadelphia in more effectively responding to an emergency situation that a member of your household with a disability may experience. Please complete the following voluntary questionnaire in full, sign the form, return it by mail, or drop it off at the nearest Police District.

If you choose to respond, the information will be submitted into the Philadelphia Police Department’s CAD system for use by Philadelphia’s 911 dispatchers. The purpose is to ensure that 911 dispatchers and emergency response personnel are aware, in advance, of any information you feel they would need to know about people with disabilities in your household in the event of an emergency.

Responding to this questionnaire is purely voluntary. You may choose to respond on behalf of all of your household members or only certain household members. If you choose to respond to this questionnaire, please be sure to provide your signature on the last page. (Your signature gives us the permission we need to process this information - without it the information cannot be processed.)

In addition, this information will be removed from our files periodically therefore this form must be submitted every two (2) years to ensure that our files are accurate.

Please notify Police Radio Training at (215) 685-3940 if there is any change to the information you provide. (i.e. change of address, phone number, etc.)

QUESTIONS

Your answers to the following questions on the attached form will assist police, fire or medical personnel when they are responding to an emergency or other call from your home, in identifying and/or assisting you, or a person in your household who has a disability. Do not include information on medications in your response.

(APPLICATIONS WITHOUT ADDRESSES OR SIGNATURES CAN NOT BE ENTERED INTO THE SYSTEM.)

This form is available in large print, audio-cassette, Braille and Spanish
Si necesita una copia en espanol, por favor llamar al (215) 685-3940.

A. Head of Household (18 years of age or older) or Agency:

1. NAME__________________________________________ AGE _______ DOB _____/_____/_____ M F

2. NAME__________________________________________ AGE _______ DOB _____/_____/_____ M F

ADDRESS _____________________________________________________(APT.) ___________________

PHILADELPHIA, PA (ZIP)___________________

TELEPHONE (______)_____________________________________

B. Does any member of your household have a disability? (Fill in blanks and Check all that apply)

1. Name_____________________________________________ Age______ DOB_____/_____/_____

Race_____________________ Sex: MALE FEMALE Height________ Weight__________

blind/low vision deaf/hard of hearing communication seizure
mental retardation physical disability mental illness other____________

2. Name_____________________________________________ Age______ DOB_____/_____/_____

Race_____________________ Sex: MALE FEMALE Height________ Weight__________

blind/low vision deaf/hard of hearing communication seizure
mental retardation physical disability mental illness other____________

3. Name_____________________________________________ Age______ DOB_____/_____/_____

Race_____________________ Sex: MALE FEMALE Height________ Weight__________

blind/low vision deaf/hard of hearing communication seizure
mental retardation physical disability mental illness other_____________

C. Does anyone in your household use a TDD/TTY? Yes No

D. Do you live alone? Yes No

E. Please use the space below to provide any additional information you feel that the Philadelphia Police or Fire Department should be aware of in order to more effectively respond to an emergency situation in your household. Is there a key holder to your property or someone to be notified in case of an emergency?

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

IMPORTANT: By signing this questionnaire, I acknowledge that the information provided above was done so voluntarily for the sole purpose of assisting the Police and Fire Departments, through their 911 system and emergency response personnel, to more effectively respond to a potential emergency in or near my household. I also understand that providing this information in no way entitles me or anyone in my household to preferential treatment, nor will it result in a more timely response by emergency response personnel. It is simply an attempt to provide emergency response personnel with information, which may be helpful when providing service to residents or occupants of my home.

IS THIS A RENEWAL APPLICATION? Yes No

Signature(s)
Head (s) of Household______________________________________________ Date __________

______________________________________________ Date __________

 

Mail form to:

Police Headquarters
Franklin Square
Communications Division Room 213
Philadelphia, PA 19106
ATTN: Sgt. Joseph Spera

If you have any questions about this form, please call:
Sgt. Joseph Spera, Police Radio Training at (215) 685-3940 (voice) or
(215) 685-3944 (fax) or (215) 685-3943 (TDD/TTY).