The Knox County Ohio First Responders have created this form specifically designed to help us improve our response to calls with the residents of our county who may have a disability. Please complete the
following voluntary questionnaire.
If you choose to respond, the information will be submitted into the Knox County Emergency Dispatch CAD
system for use by the Knox County dispatch team. The purpose of this form is to ensure that 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 completely voluntary. You may choose to respond on behalf of all of your household
members or only certain household members. If you choose to respond, 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, any information that you provide cannot be processed. If you choose not to complete the form, the timeliness or quality of emergency response will not be affected. This form simply provides our safety services with an advantage before they arrive on scene.
We ask that if you move, or the situation in the home changes, please contact us so we can make the necessary adjustments in our alert system.
Your answers to the following questions will assist police, fire or medical personnel when they are
responding to an emergency or other call from your home. The information provided will help in
identifying and/or assisting you, or a person in your household who has a disability.
Please provide the below information on the head of the household. The head of a household can be either yourself, a parent, a caregiver, or an agency.
Contact Information
If you have an emergency contact, please provide their information.
If a member of your household has a disability or medical condition, please provide their information.
If another member of your household has a disability or medical condition, please provide their information.
If another member of your household has a disability or medical condition, please provide their information.
Fill out the following information and identify the people to whom it applies.
If there is a key holder on your property or someone that can be notified in case of an emergency, please provide that information here.
Please use the space below to provide any additional information you feel that Knox County First Responders should be aware of in order to more effectively respond to an emergency situation in your household.
IMPORTANT: By signing this form, I acknowledge that the information provided above was
done so voluntarily for the sole purpose of assisting the Knox County Ohio First Responders,
through their emergency dispatch center and to their emergency response personnel, to more
effectively respond to a potential emergency in or near my household. I also understand that
providing this information does not entitle 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. Finally, I attest that I have
the legal authority to disclose the information contained in this form because I am the parent or
legal guardian of the person/s whose information is disclosed or I attest that I have the appropriate
permissions to share the above information for this purpose.
