Special Concerns Response Form - Logan's Law (HB 631)

This form collects information that will be used by our 911 dispatchers to alert first responders when they will be interacting with individuals with special concerns, such as physical, mental, or neurological disorders including, PTSD, autism, dementia, among other conditions.

This field is for validation purposes and should be left unchanged.

Individual's Identifying Information:

Name(Required)
Nickname:
MM slash DD slash YYYY

Individual's Physical Description:

Individual's Special Concerns or Conditions:

Does the Individual take medication for this condition?
This person is:
This person is:

Responsible Party Completing This Form:

Name(Required)
Address(Required)
(Leave blank if your home number is the same as your mobile number)