Let Us Know About Someone With Special Needs

Would you like to notify us of someone with special needs within Clermont County, Ohio? Please submit the form below. If you would prefer not to use our online form, we also have a PDF version that you can download, print and fill out.

Please note that any information you submit is subject to public records requests.

Please submit any questions, concerns or printed forms to:

John F. Kiskaden

Director
Clermont County Communications
jkiskaden@clermontcountyohio.gov
PH: (513) 732-7777
Fax: (513) 732-8045
2279 Clermont Center Drive, Batavia, OH 45103

Submit Online

What Would You Like to Do? [You Must Choose One]
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About the person with special needs [* denotes required fields]

Name of Special
Needs Individual *

Primary Telephone
Number for Residence
(include area code) *

Secondary Telephone
Number for Residence
(include area code)

Address
(Include apartment
or lot number) *

City *

State *

Zip Code

Check All Boxes That Apply
Someone at this location is blind or visually impaired
Someone at this location has a cognitive impairment that can involve memory, language, thinking and judgment issues
Someone at this location is hard of hearing or deaf
Someone residing at this location is physically linked to equipment required to sustain his or her life
Someone residing at this location is bedridden, uses a wheelchair, or has a mobility impairment
Someone at this location has a psychiatric impairment
Someone at this location has a speech impairment
Someone at this location may be using an electronic device for text communication utilizing a telephone line

Their Diagnosis [* denotes required fields]

Their Diagnosis *

General Symptoms - Check All That Apply

Non-VerbalMay Hurt Themselves
Medically FragileFears Flashing Lights
On MedicationFears Being Touched
Medical Alert StatusFears Loud Noises
SeizuresTourette's Syndrome
Flight RiskExperiences Sensory Overload
Aggressive in New SituationsBed Ridden

Is there any other helpful information you can share?

Characters Left:

Your Information [* denotes required fields]

Quite often, we have further questions about submissions that we receive or we would like to follow up with you. We do ask for an email address, but if you would like to be contacted by phone, please include that as well.

Your Name *

Your Email *

Your Phone
(With area code)

If you have questions about the special needs form, contact Clermont County Communications Center 9-1-1 Director John Kiskaden at (513) 732-7777 or by e-mail jkiskaden@clermontcountyohio.gov

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