911 Communications Center - Know Someone with Special Needs?

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Name of Special Needs Individual

Age

Address

Diagnosis

Check All 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 judgement 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

General Symptoms - Check All That Apply

Non-Verbal

Medically Fragile

On Medication

Medical Alert Status

Seizures

Flight Risk

Aggressive in New Situations

May Hurt Themselves

Fears Flashing Lights

Fears Being Touched

Fears Loud Noises

Tourette’s Syndrome

Experiences Sensory Overload

Bed Ridden

Hearing Impaired

Blind

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Know Someone with Special Needs?