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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 (Continued ON Next Page) 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: