Residential Emergency Response Form

RESIDENTIAL EMERGENCY RESPONSE FORM

Do you – or someone you know have a serious medical illness or has vulnerable needs?  The Residential Emergency Response Form may be effective for you or someone you know. This form is particularly helpful to first responders making them aware of your distinct circumstances prior to arriving on scene.   Access information such as lock box or garage codes can also be added to your alert to assist when entering or securing your home during your emergency. All information submitted is completely voluntary.


 
For purposes of the Residential Emergency Response Form, the definition of a medical emergency is a serious illness or disease, that, if not treated right away, could cause serious harm to you or death.  

For the purposes of the Residential Emergency Response Form, the definition of vulnerable needs is a person or people who are susceptible to harm, with access and functional needs (physically impaired, site impaired or deaf) that may interfere with their ability to receive medical care before during and after an emergency or disaster; persons who have difficulty communicating (non-verbal, autistic).

How does it work?  

The information is based on your address noted on the form. When you dial 9-1-1 for help and provide your address, the alert automatically displays in a pop up window (we call “toast”) on the CAD screen. The “toast” lists the information for responders prior to arriving on scene. 

PLEASE NOTE

  1. Spacing is limited. Only list specific or unique details that meet criteria of this form’s definitions of a medical emergency & vulnerable/special needs (listed above)
  2. DO NOT list medications, DO NOT list physicians.  We do not maintain this information.
  1. You are responsible for having an emergency “phone tree” or “emergency plan” in place for the unexpected times. Please arrange to have your pets taken care of and have your family notify others of your acute situation.  9-1-1 will NOT contact family members for you.   

Oxygen Patients:  if you are on oxygen, please notify Centre County Emergency Management 814-355-6745 or ema@centrecountypa.gov. Centre County EMA tracks this information.

A FEW THINGS TO BE AWARE OF

 

  • Centre County 911 will not place any alert on record without a completed form (signature required).
  • This information will only be shared with emergency responders/EMA -- during an emergency at the address listed on the form.

 

  • Information – if relayed – will be done by the staff at Centre County 911.        It could be relayed electronically or by radio, to police officers, firefighters, paramedics, or other emergency responders.
  • Completing the Residential Emergency Response Form, and providing the personal information it includes, is entirely voluntary.
  • You can revoke the release of this personal information -- cancel at any time.  Send letter to Centre County 911 Alerts, Willowbank Bldg, 420 Holmes St, Bellefonte, PA 16823; or email to: addressing@centrecountypa.gov.  
  • It is the resident’s responsibility to provide updates or changes to 911 (if you move, we can transfer the “remarks” to your new address as long as you reside within Centre County.)
  • The information provided will be reviewed, in writing, with the requestor every 6 to 12 months. Valid email address required.  
  • A written email reply is mandatory during the review.  If there is no response, the “remarks” are removed from record and the Alert is discontinued. 
  • If you have questions or wish to update your information email addressing@centrecountypa.gov, or mail the information to Centre County 911 Alerts, Willowbank Bldg, 420 Holmes St, Bellefonte, PA 16823.
  • Personal Contact information will not be included in your alert; 911 will not notify family members of the 911 call.

 

Residential Emergency Response Form (PDF)