Specific Response
Registry Form

The Specific Response Registry is a voluntary registry that is designed to provide advanced notice to emergency response personnel (including, but not limited to, Carmel Fire Department, Carmel Police Department, and Hamilton County Public Safety Communications (9-1-1 dispatch)) of a Resident that may have difficulty leaving a residence quickly in the event of an emergency or that may require a specific response from emergency response personnel. A Resident may have difficulty leaving a residence quickly or require a specific response from emergency response personnel for a number of reasons, including, but not limited to, a physical, mental, medical, sensory, or intellectual disability. The information provided in this form is to aid emergency response personnel in an emergency situation.

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Resident's Information:

1

Resident's First Name:

 *

Resident's First Name:

2

Resident's Last Name:

 *

Resident's Last Name:

3

DOB:

 *

DOB:

4

Gender:

Gender:

Male

Female

5

Resident's Address:

 *

Resident's Address:

Street:

Apartment Number:

City:

State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

6

Resident's E-mail:

Resident's E-mail:

7

Resident's Primary Telephone Number:

 *

Resident's Primary Telephone Number: ext.

8

Secondary Telephone Number:

Secondary Telephone Number: ext.

9

Specific/Special Need:

Specific/Special Need:

10

Reason(s) resident may have difficulty leaving residence quick in the event of an emergency:

 *

Reason(s) resident may have difficulty leaving residence quick in the event of an emergency:

Unable to Walk	Difficulty Communicating	Difficulty Following Instructions
Difficulty Hearing	Limited Vision	Other (Please Explain) If other, type text here.

11

Other/Additional information that emergency personnel should know (pets, children, adaptive equipment (prosthetics, oxygen)):

 *

Other/Additional information that emergency personnel should know (pets, children, adaptive equipment (prosthetics, oxygen)):

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Emergency Contact Information:

12

Emergency Contact Name:

 *

Emergency Contact Name:

13

Emergency Contact Phone:

 *

Emergency Contact Phone: ext.

14

Emergency Contact Second Phone:

Emergency Contact Second Phone: ext.

15

Emergency Contact E-mail:

Emergency Contact E-mail:

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Person Completing Form (if different from Resident):

16

Name:

Name:

17

Address:

Address:

Address:

Apartment Number:

City:

State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

18

E-mail:

E-mail:

19

Primary Telephone Number:

Primary Telephone Number: ext.

20

Relationship To Resident:

Relationship To Resident:

Parent

Spouse

Child

Grandparent

Other (Please Explain) If other, type text here.

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Acknowledgment & Electronic Signature:

To the extent that any information provided in this form constitutes Protected Health Information, such information is subject to the requirements and protections afforded under all applicable state and federal laws and regulations as may be amended from time to time, including the Health Insurance Portability and Accountability Act (“HIPAA”).

21

I certify that I am:

 *

I certify that I am:

the Resident (named above) that may have difficulty leaving a residence quickly in the event of an emergency or that may require a specific response from emergency response personnel; or

the Resident’s legal guardian; or

the Resident’s parent (if the Resident is under the age of 18).

I am NOT the Resident, the Resident’s legal guardian, or Resident’s parent (if the Resident is under the age of 18), but I am the Resident’s _(answer below)_ and I am completing this form because _(also answer below)_ If other, type text here.

22

To the extent that any information provided in this form constitutes Protected Health Information, I hereby authorize and consent to its release to any emergency response personnel of, but not limited to, the Carmel Fire Department, the Carmel Police Department, and the Hamilton County Public Safety Communications (9-1-1 dispatch), to be used to assist emergency response personnel in case of an emergency.

• This consent is subject to revocation at any time by notifying the Carmel Fire Department in writing, except to the extent that action has been taken in reliance on the consent.
• Any future treatment, payment, enrollment, or eligibility for benefits is not conditioned upon whether or not this release is authorized and/or consented to.
• There is potential that information disclosed under the terms of the authorization will be redisclosed by the recipient and no longer protected by 45 CFR Part 164, Subpart E.

I understand that, by providing the above information, a state, county, or municipal emergency responder, including any present and former officer, agent, and/or employee of, but not limited to, the Carmel Fire Department, the Carmel Police Department, and the Hamilton County Public Safety Communications (9-1-1 dispatch), does not assume any responsibility or duty beyond that which is provided for under applicable law.

I agree to provide timely written notice to the Carmel Fire Department of any changes to the information provided above, including, but not limited to, a change of residence or a change to the specific need(s) of the Resident.

I affirm, under penalty of perjury, that the information provided above is accurate and true to the best of my knowledge, and understand that if I have intentionally or knowingly provided incorrect information I may be subject to criminal and/or civil liability.

This information, included the consent, WILL expire every 12 months. In order to remain part of the Specific Response Registry, this form must be completed every 12 months.

I understand that my electronic signature constitutes a legal signature confirming that I acknowledge and agree to the above.

 *

To the extent that any information provided in this form constitutes Protected Health Information, I hereby authorize and consent to its release to any emergency response personnel of, but not limited to, the Carmel Fire Department, the Carmel Police Department, and the Hamilton County Public Safety Communications (9-1-1 dispatch), to be used to assist emergency response personnel in case of an emergency. This consent is subject to revocation at any time by notifying the Carmel Fire Department in writing, except to the extent that action has been taken in reliance on the consent. Any future treatment, payment, enrollment, or eligibility for benefits is not conditioned upon whether or not this release is authorized and/or consented to. There is potential that information disclosed under the terms of the authorization will be redisclosed by the recipient and no longer protected by 45 CFR Part 164, Subpart E. I understand that, by providing the above information, a state, county, or municipal emergency responder, including any present and former officer, agent, and/or employee of, but not limited to, the Carmel Fire Department, the Carmel Police Department, and the Hamilton County Public Safety Communications (9-1-1 dispatch), does not assume any responsibility or duty beyond that which is provided for under applicable law. I agree to provide timely written notice to the Carmel Fire Department of any changes to the information provided above, including, but not limited to, a change of residence or a change to the specific need(s) of the Resident. I affirm, under penalty of perjury, that the information provided above is accurate and true to the best of my knowledge, and understand that if I have intentionally or knowingly provided incorrect information I may be subject to criminal and/or civil liability. This information, included the consent, WILL expire every 12 months. In order to remain part of the Specific Response Registry, this form must be completed every 12 months. I understand that my electronic signature constitutes a legal signature confirming that I acknowledge and agree to the above.

Signature:

Today's Date:

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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