Request a Disability Indicator form for Landline, Wireless and VoIP Consumers

What you need

The Massachusetts Disability Indicator Program offers a free, voluntary service that alerts 9-1-1 personnel that an individual with a disability may have unique safety, communications or other needs in case of an emergency. This service was developed in consultation with organizations representing the mobility, hearing, speech and sight impaired communities. This service is available for landline, wireless and VoIP telephone service providers. It is necessary to request the service through completion of the Disability Indicator Form located in the link below.

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How to request 

It is necessary to submit the Disability Indicator Form to the 9-1-1 Municipal Coordinator in order to assist public safety personnel in responding to an emergency at the address listed on the form. If the Disability Indicator Form is not completed properly, the information will not be entered into the 9-1-1 system. The Municipal Coordinator for the towns of Cohasset, Hingham, Hull, and Norwell is Johnathan Gordon, Deputy Director of the SSRECC. Please email the signed form to jgordon@ssrecc.org or by mail to: J. Gordon South Shore Regional Emergency Communications Center 210 Central St 2nd Fl Hingham, MA 02043.

This is a standardized form created to encourage participation from all persons with disabilities. There is an extensive range of disabilities and medical conditions. The disability indicator categories listed on the Disability Indicator Form may be considered too broad for some when considering the extensive range of disabilities. However, the information requested on the Disability Indicator Form is intended to remain sensitive to those who may not wish to provide detailed information.

Once the Disability Indicator Form is submitted to the 9-1-1 Municipal Coordinator, the 9-1-1 Municipal Coordinator signs and submits the form to the 9-1-1 service provider for entry into the 9-1-1 location database.  The 9-1-1 Municipal Coordinator retains the original form for its records and for use with annual verification of the database.

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More Information

The information provided for input into the 9-1-1 system will remain until a change is requested or until a request is made to have the information removed. It is necessary to notify the 9-1-1 Municipal Coordinator when there is a change in the information on the form. When there is a change, it is necessary to complete a new form and send it to the 9-1-1 Municipal Coordinator.

Please note: It's important to submit a new Disability Indicator Form upon change of service provider, telephone number, or address, or to add or delete a disability, or to add a new resident with disability.

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Courtesy: Massachusetts State 911 Department​