Special Needs Questionnaire

MARSHALLTOWN POLICE DEPARTMENT

SPECIAL NEEDS QUESTIONNAIRE

Please fill out and return to the Marshalltown Police Department, 22 North Center Street, Marshalltown. If you have any questions please contact Sgt Tricia Thein or Teresa Lang at (641) 754-5725.

Today’s Date: / Diagnosis/Condition:
Form completed by: / Relationship:
Personal Information:
Full Name: / DOB: / Sex:
Home Address:
Home Phone: / Cell Phone:
Social Security #: / Iowa ID/DL #:
Physical Description:
Height: / Weight: / Age: / Build: / Eye Color:
Hair: / Glasses: Y N / Photo Available: Y N
Distinguishing Marks (scars/moles/tattoos/piercings):
Overall Appearance:
Next of Kin
Name:
Address:
Home Phone: / Cell Phone:
Relationship to Subject:
Emergency Contact
Name:
Address:
Home Phone: / Cell Phone:
Name:
Address:
Home Phone: / Cell Phone:
Family Doctor/Pediatrician
Name:
Office address:
Office phone: / Cell phone:
Other contact information:
Caregiver
Name:
Address:
Home phone: / Cell phone:
School
Name:
Address:
Teacher’s name: / Phone number:
Outdoor Experience
Familiar with area: Y N / Ever lost before: Y N
When: / Where located:
Health/General Condition
Overall health:
Overall physical condition:
Known medical/dental problems:
Handicaps/deformities/prosthetics:
Known psychological problems:
Medication: / Dosage:
Medication Side Effects:
Additional Information for Individuals with Special Needs to Address Immediate Life Saving Efforts
Tracking technology device worn/carried: Y N / Medical Alert Tags/Labels: Y N
If so, how are tracking measures initiated:
Individual attracted to water? Y N / Specific body of water?
Individual able to swim? Y N
Individual attracted to roadways/highways? Y N / Specific which one(s):
Individual attracted to: Trains Heavy equipment Airplanes Fire trucks
Other vehicles, specify:
Will individual get in parked cars? Y N
Individual have siblings with special needs: Y N
Siblings wandered before: Y N / Where found:
Favorite places/locations: / Quite place?
Individual:Verbal Non-Verbal / Type of communication device, if used:
Reaction when name called:
Responds to voice of: Mother Father Other, specify:
Favorite song: / Favorite toy:
Favorite character:
Knows parents’: Names Home Address Phone Number
Other contact information, specify:
Dislikes:
Fears:
Behavioral triggers:
Reaction to: / Sirens:
Aircraft:
Canine/Search dog/Barking:
People in uniform/searchers:
Loud noises:
Response to pain/injury:
Response to being touched:
Sensory, medical, dietary issues/requirements:
Methods used to calm child once upset:
Special-Needs conditions:
Any other beneficial information for emergency responders:
Permission to flag individual in police database in case of emergency or fire? Y N

*Add additional sheets as necessary.

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