Fillable Form 4503 PROJECT LIFESAVER CLIENT FILE This Document Is For (Clark County Board of Commission)

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Form 4503 PROJECT LIFESAVER CLIENT FILE This Document Is For (Clark County Board of Commission)

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The Form 4503 PROJECT LIFESAVER CLIENT FILE This Document Is For (Clark County Board of Commission) form is 5 pages long and contains:

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  • 183 other fields

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File type: PDF

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BROWSE CLARK COUNTY BOARD OF COMMISSION (OH) FORMS

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PROJECT LIFESAVER CLIENT FILE
This document is for both children and adults. Please fill out any and all
information that is applicable to the person / client who will be enrolled.
This form is designed for Custodial Care Givers to provide, in advance, certain information that will be
useful to Search Teams, should the need arise. Providing the information in advance of the need will
allow Search Management Personnel the necessary information to establish a more effective search
response. All questions highlighted in RED are required.
Client’s Personal Data: (Write n/a if the question isn't applicable to the client)
Male Female
Race:
Phone Number:
Spouse is: Living Deceased
Most recent place of work:
No
Other Cognitive Impairment (Explain):
Diagnosis:
(Select all
that apply)
NO
Has Client ever wandered before? YES
Where were they when they wandered:
Located Returned by Themselve
When / Time of Day (Mark all that apply):
Located by searchers or returned by himself/herself?
Location(s) found:
NO
Safety Actions taken:
Is the Client DANGEROUS to himself/herself or others? YES
If yes, Explain:
Does the Client become upset easily? YES
NO
What tends to calm them?
Sex:
Most recent address:
Address:
School Name:
Teacher's Name:
Name of Spouse:
Most recent occupation:
Does Client speak? Yes No
Communicates both Written and Spoken? Yes
No
Spoken word only? Yes
If Client does not understand English, what language is understood?
Attending Physician / Pediatrician Name & Address:
Attending Physician / Pediatrician Phone Number:
Morning
Afternoon
Evening
Nickname:
Birthdate:
Name:
Dementia
Alzheimer's Disease
Autism
Other Cognitive Impairment
11/2019
Page 1 of 5
2. Will Client talk to strangers?
YES
NO
PROJECT LIFESAVER CLIENT FILE
This document is for both children and adults. Please fill out any and all
information that is applicable to the person / client who will be enrolled.
All questions highlighted in RED are required.
Client’s Personal Information: (Write n/a if the question isn't applicable to the client)
1. What reaction does Client have if injured?
(Cry,shout,etc.)
3. How might the person react to sirens, helicopters, airplanes, search dogs, people in uniform, or those
participating in a search team?
4. Is the Client attracted to water?
Yes
No
5. Can they swim?  Yes
No
8. Candy/Gum:
YES
7. Tobacco Products: YES
10. Lighter: YES NO
9. Matches: YES NO
11. Purse or Wallet YES NO Please describe:
12. Jewelry / Watch YES NO Please describe:
13. Other (describe):
Equipment:
Cane Walker
Other (describe):
6. How good is the Client’s communication ability? None
Personal Articles Normally Carried by the Client:
Poor
Fair
Good Excellent
Experience:
15. Familiar with area? YES
NO
If not local, what other areas are known to Client?
YES
NO
YES
NO
YES NO
YES
NO
Personality / Habits:
14.
21. Drink Alcohol? YES
NO
NO
NO
If yes, Brand:
If yes, Brand:
16. Does the Client ever go out alone?
17. Has the Client ever taken first-aid training?
18. Was the client ever involved in Scouting?
19. Does the Client have military experience?
If yes, job duty in Military:
20. Smoke?
YES
NO If yes, Brand:
22. Hobbies/Interests:
11/2019
Page 2 of 5
PROJECT LIFESAVER CLIENT FILE
This document is for both children and adults. Please fill out any and all
information that is applicable to the person / client who will be enrolled.
All questions highlighted in RED are required.
Dogs
People
Noises
The Dark
Client’s Personal Information:
23. Where was Client born and raised? (city,state)
24. Religious?
YES
NO
What faith?
Yes
No
YES
NO
YES
NO
YES
NO
31. Does the Client have decreased knowledge of current events or tend to re-live events in his/her life?
YES
NO
YES
NO
YES
NO
*Client should not have access to a vehicle or keys to family vehicles.
Client’s Fears: (Check all that apply):
30. Can the Client travel to familiar locations?
Explain:
NO
YES NO If yes, describe:
32. Does the Client sometimes clothe himself/herself improperly? YES
(Example: Putting shoes on the wrong feet, adding underwear over clothing?)
NO
Person in Uniform
Other Describe:
25. What does Client value most (ex: favorite toy / trinket,person, etc.)?
26. Which family member is Client closest to?
Relationship:
27. Client a Member of any Organization: (Example: Church, Amvets, AARP, DD)
If yes, explain:
28. Does the Client remain oriented to Time and Person?
29. Does the Client recognize familiar persons and faces?
33. Does the Client remember his/her own name and the names of spouse and or children?
34. What is the Client’s sleep pattern?
35. Does the Client suffer from frequent personality and emotional changes? YES
Explain:
36. Does the Client suffer from delusions? YES NO
(Ex: See imaginary visitors, Talk to his/her own reflection in the mirror, Imagine that their spouse is an imposter, etc?)
If yes, explain:
37. Does the Client have a valid driver’s license?
38. Does the Client have access to a vehicle?*
If yes, (Make, Model, Description):
11/2019
Page 3 of 5
Client’s Physical Description:
Height: feet inches
Hair color:
Eye Color:
Weight:
pounds
Hair style:
False Teeth?
YES NO
Mustache?
YES
NO
Beard?
YES
NO
Balding? YES NO
Sideburns?
YES
NO
NO
YES
Distinguishing marks, scars, tattoos, etc. ?
Describe:
Does Client wear glasses? YES NO
Contacts?
YES
NO
If Client wears glasses or corrective eyewear, what degree of vision does he/she have without the
eyewear:
None
Poor
Fair
Does Client wear a hearing aid? YES
NO
If yes, what type of hearing without aid?
None
Poor
Fair
Health/Psychological / Sensory Condition:
YES NO
YES NO
Any known physical handicaps?
If Yes, describe:
Any known medical problems?
If Yes, describe:
List medication taken regularly using correct name of drug and dosage being taken:
Consequences of NOT taking medications:
Any Psychological Issues: YES NO If yes, explain:
Sensory Issues? YES NO If yes, explain:
PROJECT LIFESAVER CLIENT FILE
This document is for both children and adults. Please fill out any and all
information that is applicable to the person / client who will be enrolled.
All questions highlighted in RED are required.
11/2019
Page 4 of 5
5
7
Work Phone: Other Phone:
PROJECT LIFESAVER CLIENT FILE
This document is for both children and adults. Please fill out any and all
information that is applicable to the person / client who will be enrolled.
All questions highlighted in RED are required.
1.Contact Person Name:
Relationship to Client:
Full Address:
Home Phone:
2.Contact Person Name:
Relationship to Client:
Full Address:
Please list two (2) additional contacts:
Caregiver / Primary Contact Information:
Primary Contact Person Name:
Relationship to Client:
Full Address:
Home Phone:
Work Phone:
Other:
Email Address:
Home Phone:
:Other PhoneWork Phone:
----------------------------------------------------------------------------------------------------------------
Sheriff's Office Use Only
Date Transmitter Placed: _______________________Frequency #: _______________________
Facility / Organization: Clark County Sheriff’s Office
Address: 120 North Fountain Avenue, Springfield, Ohio 45502
Office Phone: 937-521-2050
Representative filling out this form: ________________________________________________
PL Servicer that places transmitter on: _______________________________________________
----------------------------------------------------------------------------------------------------------------
After you have completed the form, save a copy and email it to: wholt@clarkcountyohio.gov
Or you can mail your completed form to:
Clark County Sheriff's Office
Attn: Wendy Holt
120 North Fountain Avenue
Springfield, Ohio 45502
11/2019
Page 5 of 5
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Form 4503 PROJECT LIFESAVER CLIENT FILE This Document Is For (Clark County Board of Commission)

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Completed 6 August 2020

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