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

North Carolina Pilot Program

Having trouble completing the Program Form online?
Download Program Form
Fax completed form to: 608-960-4003

Care Coordinator

Legally Responsible Person/Primary Contact

Equipment

Sensors always in use are: Panel, Smoke Detector, Personal Pagers - (necklace, watchband and/or mounted bathroom pager), Flood Sensor (in bathroom), Thermostat Sensor.

Please write "Active" or "Inactive" below each other sensor type. Add detailed information for tracking for each sensor after you have identified if it is active or inactive. Please provide email addresses for reports.

Please indicate duration for bed sensor: 3 mins, 6 mins, 15 mins, or 30 minutes. *Bed sensor activates only if individual is out of be for predetermined amount of time.