HomeMy WebLinkAboutLost Application Forma Iowa City Police Department Loved Ones Safe and Together (L.O.S.T.)Program
Information Form
The information you provide will assist the Iowa City Police Department in identifying citizens who
have the potential of becoming lost or disoriented due to a medical condition.The information will be
kept confidential in accordance with Chapter 22.7,paragraph 18,subsection A and B until law
enforcement deems it necessary to release the information.
Patient Information
Last Name:____________________First Name:__________________Middle:_______1LFNQDPHBBBBBBBBBBBBBBBBBBBBBB
Address:___________________________City:_________________State:_______=LS&RGHBBBBBBB%LUWK'DWHBBBBBBBBB
M: F: Race:________Height:_______:HLJKWBBBBBBB +DLU&RORUBBBBBBBBBB (\H &RORUBBBBBBBBB
Additional Identifiers (glasses,scars,marks,tattoos,piercing,etc.)________________________BBBBBBBBBBBBBBBBBBBBBBBBBB_
Vehicle Informations (if applicable): Plate #________ Year____ Make__________ Model________ Color________ Body_______
Does the Person Have:
Alzheimers? Related Dementia? Autism? Cognitive Disability? Other Memory Loss Condition? ____________
Level Of Support Needed:_____________________________________________________________________________________
Method of Communication: Verbal? Non-Verbal? Notes:_______________________________________________
Characteristics:
Sensory Issues: Yes No Details:________________________________________________________________
Touch: Yes No Details :___________________________________________________________
Sensory Issues: Yes No Details:___________________________________________________________________
Touch: Yes No Details :___________________________________________________________________
Sounds: Yes No Details:_________________________________________________________________ Bright Lights: Yes No Details:_________________________________________________________________ Processing Delays: Yes No Details:_________________________________________________________________
Eye Contact: Good Fair Poor Details:________________________________________________________________
Stimming Behavior: Describe:____________________________________________________________________________
Fears: Describe:_____________________________________________________________________________
Dislikes/Triggers: Describe:____________________________________________________________________________
Favorite Objects/Topics/Foods:____________________________________________________________________________
PreCritical Episode Signs:________________________________________________________________________________
Critical Episode Behavior: ________________________________________________________________________________
Calming Strategies For Episodes:___________________________________________________________________________
Violence or Prior Contact with Police:_______________________________________________________________________
Alcohol/Drug Issues: Yes No
Weapons In The Home: Yes (if answered Yes, please see below) No
Are Weapons Properly Secured: Yes No Details:________________________________________________________
Wandering:
Prior Wandering Incident: Yes No Details:______________________________________________________________
Where Has This Person Been Located Previously?_____________________________________________________________
What Is The Closest Water Area To Residence?_______________________________________________________________
Please List All Lakes, Ponds, Streams, Ditches and Drainaige Areas Nearby:________________________________________
____________________________________________________________________________________________________
Please List Favorite Hiding Area At Home:___________________________________________________________________
Please List Any Favorite Places In The Neighborhood/Community:________________________________________________
Please List Any Place of Employment The Person May Go To : ___________________________________________________
Will This Person Respond To Thier Name Being Called? Yes No Sometimes
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Medical Conditions of Patient:_____________________________________________________________________________________
Caretaker Information
Last Name:_________________________First Name:__________________________
Address:___________________________City:_____________________State:_____ ZipCode:________
Home Phone:__________Cell:Phone____________Work Phone:____________
Email Address:______________________________________
Relationship to Patient:________________________________
Second Caretaker Information
Last Name:_________________________First Name:__________________________
Address:___________________________City:_____________________State:_____ ZipCode:________
Home Phone:__________Cell:Phone____________Work Phone:____________
Email Address:______________________________________
Relationship to Patient:________________________________
(Additional names can be added on separate sheet)
Name of Person Requesting Application:__________________________________
Signature of Requesting Person _____________________________________Date:____________
(Please present the form in person,with photo I.D.to the Iowa City Police Department,all forms must be signed.)
In the event of a missing person’s report the Iowa City Police Department is authorized and will release the victim’s
name, age, basic physical descriptors, last known location, last known clothing, and image.
Is The Person Enrolled In Medical Alert And Safe Return? Yes No Identification Number:____________
What Type Of Medical Alrt Jewelry Will The Person Be Wearing? ID Necklace ID Bracelet
Would you like to have a Police Officer visit with you in person about this program? Yes No
(Please provide a photograph of the person, if one is not available a Police Officer will take one for you.
All photographs become the property of the Iowa City Police Department)
Would you like to have a Police Officer photograph the Person for their file? Yes No
Please List any Symptoms Or Behaviors An Officer May Expect To See From This Person: