North Carolina

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Fax completed form to: 608-960-4003

Date

Name(s) of Guests:

Care Coordinator

Name

Phone

Legally Responsible Person/Primary Contact

Name

Phone

Anticipated dates of member's stay:

Cell Phone? If Yes, provide cell number:

Evening staff Arming/Activating System Required? If Yes, provide time below:

Morning staff arrival required (if required, system remains on)? If Yes, provide time below:

Responder Name

Responder Cell Phone

Back-up Responder Name

Back-up Responder Cell Phone

Activity Reports

Daily
Weekly
Monthly

Email(s) where reports are sent

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.

Exterior Door Sensors

Windor Sensors

Cabinet Sensors

Refrigerator Sensor

Freezer Sensor

Bed Sensor (Please indicate time setting)

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.

Motion (1):

Motion (2)