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2. Illinois Premise Alert Program

4. The Illinois Premise Alert Program (PAP) is a useful tool for both Police and Fire responders and dispatch centers to be aware of specific information or instructions regarding persons with special needs or disabilities that require immediate attention when calls for service are requested to a location. This form assists in the accurate entry and record keeping of Premise Alert Program notes requested to be put into the emergency response database. Information submitted is considered confidential as cited in Section 25 of Public Act 096-0788

   This information is kept on file for a period not to exceed two years. The information will self expire two years from the date received by the Village and must be resubmitted.

8. Information Regarding the Individual with Disability
10. Name*
11. Nickname
12. Date of Birth*
14. Home Address*
15. City*
16. State*
17. ZIP Code*
19. Gender*
20. Height*
21. Weight*
22. Eye Color*
24. Race*
25. Hair Color*
27. Place of Employment
28. Employer Contact
30. Work Address
31. City
32. State
33. ZIP Code
35. Primary Physician Name*
36. Physician Phone Number *
38. List any medications taken by the individual*
40. Is the individual verbal or nonverbal?*

    1. Verbal
    2. Nonverbal
41. Living Arrangements*

    1. Home with Family
    2. Independent Living
    3. With a Roommate
    4. Residential Facility
    5. Other
42. Prefered Method of Communication

    1. Speaking
    2. Sign language
    3. Picture boards
    4. Written words
    5. Other
44. Personally Identifying Characteristics *
45. Medical Condition/Diagnosis*
47. Are there any specific phrases, words, or repetitive behaviors used in stressful/scary istuations that first responders can use to deescalate an incident?*
48. Does the individual have any favorite attractions/locations where they may be found?*
50. Are there any sensory or environmental triggers that first responders should be aware of? (loud noises, bright or flashing lights, smells, etc.)*
51. Does the individual have any favorite toys, movies/TV shows, likes/dislikes, music or discussion topics?
53. Are you interested in having a first responder meet with your family and loved one?

    1. Yes
    2. No

    Meeting with a first responder prior to any emergency could prove advantageous down the road. 

55. Special Considerations*

    Include any additional information that can be helpful for first responders.

57. Photo of Person with Disability*
61. Information on Person Completing Form
63. Name*
64. Phone Number*
65. Email Address*
67. Relationship to Individual*
    -- Select One --ParentFamily MemberCaregiverAgency Case ManagerIndividual with Disability
71. Emergency Contact Information of Individual with Disability
73. Name*
74. Phone Number*
75. Alternate Number
77. Address*
78. City*
79. State*
81. Name*
82. Phone Number*
83. Alternate Number
85. Address*
86. City*
87. State*
89. Name
90. Phone Number
91. Alternate Number
93. Address
94. City
95. State
Leave This Blank:


97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit

* indicates a required field