North Carolina Pilot Program

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Fax completed form to: 608-960-4003

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NOSS Supports Checklist
Date
Name(s) of Guest
First Last
Birthdate(s) of Guest
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
If yes - phone number
Evening staff Arming/Activating system
If yes - time
Morning staff arrival required: (if required, system remains on)
If yes - time
Responder
Cell Phone
Back-up Responder
Cell Phone
Activity Reports
If Yes:
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**

NOSS Supports Checklist