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Police Department Application for Specials Concern

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Steps

1. Step One This section is complete This section is incomplete
2. Step Two This section is complete This section is incomplete

Step One

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 Phone Number:
Cell Phone Number:
Birthdate:
Race:
Gender:
Height:
Weight:
Hair Color:
Eye Color:
Employer/School Address:
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?
Continue

Step Two

Suggestions and techniques that can be taken to resolve a confrontation successfully:
This person is:
1. Sensitive to light
2. Likely to fight
3. Violent
1. Likely to hide
2. Subject to seizures
3. Other
1. Sensitive to touch
2. Afraid of police/uniformed people
If other, please explain:
Responsible Party Completeing This Form
Name:
Relationship:
Address:
Home Phone Number:
Cell Phone Number:
Signature:
Date:
Date:
Emergency Contact Information
Name:
Relationship:
Home Phone Number:
Cell Phone Number:
Name:
Relationship
Home Phone Number:
Cell Phone Number: