Full Text
Page 1 of 2 Pickens County E-911 Special Concerns Response Information Logan’s List (O.C.G.A 38-3-182) General Information About the Special Concerns Person Name: Nickname: Address: Home Telephone Number: Cellular Phone Number: Birthdate: Race: Gender: _____Height: _____Weight: Hair color: Eye color: Employer/School Address (Only if in Pickens County): 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 techniques that can be taken to resolve a confrontation successfully: This person is: o Sensitive to light o Likely to hide o Sensitive to touch o Likely to fight o Subject to seizures o Afraid of police/uniformed people o Violent o Other: ---PAGE BREAK--- Page 2 of 2 Responsible Party Completing This Form Name: Relationship: Address: Home Telephone Number: Cellular Phone Number: Signature: Date: Emergency Contact Information Name: Relationship: Address: Home Telephone Number: Cellular Phone Number: Name: Relationship: Address: Home Telephone Number: Cellular Phone Number: Name: Relationship: Address: Home Telephone Number: Cellular Phone Number: o New Applicant o Updated Info o Renewal Date Received: Entered in CAD by: Date/Time: Copy sent to law enforcement: Date/Time: Copy sent to fire department: Date/Time: Copy sent to EMS: Date/Time: Copy sent to other: Date/Time: SIGN