Premise Alert Program Notification Form 

The Illinois Premise Alert Program (Public Act 096-0788) provides for Public Safety Agencies in the State of Illinois to allow people with special needs to provide information to police, fire and EMS personnel to be kept in a database.  The information can then be provided to responders dealing with situations involving the Special Needs individuals. 

The purpose of this program is to offer guidance and direction to the public safety workers in responding to and assisting those people with special needs or disabilities or both with whom they will have contact in the performance of their duties and responsibilities.

Disability is defined as an individual with physical or mental impairment that substantially limits one or more of the major life activities; a record of such impairment; or when the individual is regarded as having such impairment. This also includes but not limited to, a medical impairment that requires the use of pressurized oxygen. 

Special needs is defined as those individuals who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by individuals generally. This also includes but not limited to, a medical impairment that requires the use of pressurized oxygen.

In order for information to be entered into the Premise Alert Program database the following must be completed:

1.  Proper form
2.  Written permission obtained from one of the following:
a. parent

b. guardian
c. family member
d. caregiver of the individual

3.  Verification must be completed prior to entry into the database.
The verification can be completed by one of the following:
a. the individual
b. family member c. friends
d. caregivers
e. medical personnel familiar with the individual 

The notification expires two (2) years after the date it was submitted. If not renewed it will be removed from the database. It may be renewed by completing another form. During the 2-year time if any changes occur, please update the information by filing an amended request form.

This includes but not limited to the following:
1.  Change of address
2.  Change in condition
3.  No longer the need to be in the database

The forms may be completed and returned to the following address: Bureau County 9-1-1 Office

615 Elm Place
Princeton, IL 61356
ATTN: Premise Alert Program

OR Call 815-872-1420 ask for Dawn Porter

-Premise Alert Program Form .pdf