Madison Fire & Rescue invites the City of Madison residents to participate in providing valuable information regarding any special circumstances. The information collected is strictly confidential and will be used only to assist firefighters on dispatch in the event of an emergency situation at your home. Please note, it is the responsibility of the applicant to provide updated information, as necessary, to Madison Fire & Rescue by filling out a new form, or in person at 101 Mill Rd, Madison.

Patient Information

Patient Name*

Address*

City*

Zip*

Phone*

Number of persons with disability in home?*

Number of service animals in home?

Medical History*

Total Immobility Total Hearing Loss Total Sight Loss Mental Health Issues Mobile with Assistance Partial Hearing Loss

Partial Sight Loss Alzheimers/Dementia Autism Aspergers Known Diabetic

First Responder Considerations- Does the patient exhibit any of the following behaviors?

Wondering Visual Sensitivity

Auditory Sensitivity Violence towards First Responders

Details of Residence

Location of bedroom in home*

Front of house Rear of house Basement

First floor Second floor Third floor

Oxygen in use in home*

Yes

No

Are there working smoke alarms?*

Yes

No

If yes, how many?

Is there a chair, stair lift or elevator in the home that can be utilized if necessary by emergency personnel?

Chair Stair Lift

Elevator

Is the individual a self advocate?*

Yes

No

Key Location

Door Code?

Any other information that you would like us to know that may be helpful in assisting you?

Caretaker or Keyholder Contact Information

Caretaker or Keyholder Name*

Caretaker Lives With Patient

Yes

No

Caretaker or Keyholder Phone Number