Chatham County, Georgia

Special Concerns Response Information Logan's Law (HB 631)

Fields with * are required.

General Information About the Person With Special Concerns

Name *

Nickname

Address *

Home Telephone Number

Cellular Phone Number

Birthdate

Race

Gender

Height

Weight

Hair color

Eye color

Employer/School Address
(Only if in Chatham 911 Communications Services jurisdiction)

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? *

Suggestions and techniques that can be taken to resolve a confrontation successfully: *

This person is:

Sensitive to light

Likely to hide

Sensitive to touch

Likely to fight

Subject to seizures

Afraid of police/uniformed people

Violent

Other

Responsible Party Completing This Form

Name *

Relationship *

Address *

Home Telephone Number

Cellular Phone Number

Emergency Contact Information

1st Contact

Name

Relationship

Address

Home Telephone Number

Cellular Phone Number

2nd Contact

Name

Relationship

Address

Home Telephone Number

Cellular Phone Number

3rd Contact

Name

Relationship

Address

Home Telephone Number

Cellular Phone Number

BY SUBMITTING THIS FORM, I AM SIGNING THIS FORM ELECTRONICALLY, AND I AGREE THAT MY ELECTRONIC SIGNATURE IS THE EQUIVALENT OF MY MANUAL SIGNATURE ON THIS FORM.

I understand it is my responsibility to resubmit this form annually to maintain my information on the Logan's List. Any changes required prior to the annual update, must be submitted by completing a new form. Please allow three (3) business days for this information to be updated in our system.