NIGHT OWL SUPPORT SYSTEMS, LLC | P.O. BOX 259293 | MADISON, WI 53725 | TOLL FREE: 877-559-1642 | FAX: 608-960-4003
info@nossllc.com
608-960-4001
Home
Services
Team
Referral Forms
NOSS Referral Form
Dane County Referral Form
North Carolina Pilot Program
Careers
Testimonials
Outcomes
Contact
North Carolina Pilot Program
Having trouble completing the Program Form online?
Download File
Fax completed form to: 608-960-4003
Upload Completed Form
Want to upload an already filled out form?
Noss Supports Checklist
Date
Name(s) of Guest
First
Last
Birthdate(s) of Guest
First
Last
Diagnosis
Case Manager
Name
First
Last
Phone
Email
Primary Contact
Name
First
Last
Phone
Email
Anticipated dates of your stay
Cell Phone number for guest
No
Yes
If yes - phone number
Evening staff Arming/Activating system
No
Yes
If yes - time
Morning staff arrival required: (if required, system remains on)
No
Yes
If yes - time
Responder
Cell Phone
Back-up Responder
Cell Phone
Activity Reports
Yes
No
If Yes:
Daily
Weekly
Monthly
Email(s) where reports are sent
Other important information
Equipment available to guests
-Panel (Always in use)
-Smoke Detector (Always in use)
-Personal Pagers – (necklace, watchband and/or mounted bathroom pager), Flood Sensor (in bathroom) (Always in use)
-Thermostat Sensor (Always in use)
-Exterior Door Sensors
-Window Sensors
-Cabinet Sensor
-Refrigerator Sensor
-Freezer Sensor
-Bed Sensor (sends an alert if someone has been out of bed for a predetermined amount of time)
-Motion Sensors
**Please note this form is for the Remote Pilot Home ONLY. If you will be utilizing NOSS services in your home, please fill out the NOSS Referral Form**
North Carolina Pilot Program
Having trouble completing the Program Form online?
Download FileFax completed form to: 608-960-4003