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
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North Carolina Pilot Program
CLC OD Form
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North Carolina Pilot Program
Having trouble completing the Program Form online?
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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
Gender
Ethnicity
White
Black
Hispanic
Native American
Asian/Pacific Island
Other/Unknown
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**
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North Carolina Pilot Program
Having trouble completing the Program Form online?
Download FileFax completed form to: 608-960-4003