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Special Concerns Response Form-Logan’s Law (HB 631)
Special Concerns Response Form-Logan's Law (HB 631)
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Birthdate
Race
Gender
Height
Weight
Hair Color
Eye Color
Employer/School Address
(Only if in Toombs County 911 jurisdiction)
Special concern or condition
Medications
How does this medication affect actions, responses, senses, the potential for violence. etc.?
Please list any activations or triggers which may escalate an encounter? What actions should be avoided, if possible, by first responders?
Suggestions and tecniques that can be taken to resolve a confrontation successfully:
Please Answer Yes or No - This person is:
Sensitive To Light, Yes or No
Likely to hide. Yes or No
Sensitive to touch. Yes or No
Likely to fight Yes or No
Subject to seizures Yes or No
Afraid of police/uniformed people Yes or No
Violent Yes or No
Other
Responsible Party Completing This Form
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Home Telephone Number
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Signature
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Date
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Emergency Contact Information
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Address
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Example: 12
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