Calumet County Project Safe Response

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* Participant's Name

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* Preferred Name (Nickname/Shortened Name, if Applicable)

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* Address

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* Birthdate (MM/DD/YYYY)

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* Number of People in Home

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* Involved with County Human Services?

Yes

Physical Description

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* Participant's Gender

Female

Male

Other (specify)

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* Participant's Physical Characteristics

Height

Weight

Hair Color

Eye Color

Scars/Marks/Tattoos (other identifying marks)

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* Glasses?

Yes

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* Dominate Hand

Left-Handed

Right-Handed

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* English Speaking?

Yes

Other (please specify)

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* Vehicle individual has access to or may operate

Make

Model

Color

License Plate

Emergency Contact Information

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* Emergency Contact

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* Relationship

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* Emergency Contact Address

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* Emergency Contact Phone Numbers

Cell

Home

Work

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* Alternative Emergency Contact

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* Alternative Contact Relationship

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* Alternative Contact Address

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* Alternative Contact Phone Numbers

Cell

Home

Work

Medical Information

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* Official Diagnosis

Dementia

Autism

Other (please specify)

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* Conditions Related to Diagnosis

Non-verbal

Difficulty Understanding Language

Combative

Need to Pace

Difficulty with Balance

Explain Any of the Above (If Needed)

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* Other Relevant Medical Conditions

Visually Impaired

Blind

Hearing Impaired

Deaf

Diabetic

Prone to Seizures

Has Needed Medications

Explain Any of the Above (If Needed)

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* Prescription Medication Information

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* Additional Information for First Responders

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* Preferred Hospital

Individual's Historical and Other Important Information

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* Previous Places of Employment

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* Job Title(s) Held in Career

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* Previous Addresses Lived

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* Current/Previous Schools Attended

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* Locations Individual likes to Visit

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* Behaviors or Characteristics of Individual that may Draw Attention

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* Individual's Favorite Objects, Music, Topics of Conversation, Hobbies

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* Things that are Upsetting to the Individual

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* Method of Preferred Communication if Non-Verbal (Sign Language, Written Word, Etc.)

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* Phrases or Topics that get a Positive Response from Individual

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* Suggested De-Escalation Methods

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* Does the Individual Wear Identifying Jewelry or Cards?

Yes

If yes, what?

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* Does the Individual have any Tracking Devices?

Yes

If yes, what?

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* Please Upload a Current Photo of the Individual

PDF, PNG, JPG, JPEG file types only.

Choose File

If you need assistance with the form, obtaining a picture, or if you have questions, please contact the ADRC at (920) 849-1451. Contact person for individuals on the registry will be contacted annually to confirm information remains accurate and up to date.

The information given on this form is confidential. This information will be maintained by the Calumet County Aging and Disability Resource Center and Calumet County Sheriff’s Office. It will be shared with law enforcement, ADRC and the Department of Health and Human Services.