Special Needs
Emergency Information Form
Please complete the following form and give to your local 911 call center, local police and fire
departments and rescue squads. (NOTE: The form can be completed on-screen but cannot be
saved to your computer, as it is a PDF document. Please complete the form and print it. Be sure
to print a copy for your personal records.) This information can be added to most 911 emergency
response systems and can be programmed to appear on a computer screen when an emergency
call is made from your home. The information will alert emergency responders, prior to their
arrival, to the possibility of a unique situation at your home, involving a person with special
1. Be sure to attach a photo of the adult or child with special needs to the form. Update this
photo routinely.
2. Give as many details as possible regarding characteristics and behaviors that may attract
attention or may be misunderstood. For example: if the person repeats everything that is
said, flaps their hands, won’t look at the person talking to them, etc. Give details as to the
likes and dislikes of the person with the special needs.
3. Give as specific information as possible for sensory, medical or dietary issues. For
example: the flashing lights or loud sirens on emergency vehicles upset the person; the
person does not feel pain even when they are obviously in pain, the person feels pain when
lightly touched, etc.
4. Attach the following information to the form before giving it to your local 911 call
center/local police/fire departments:
A. Map and addresses of nearby properties with water sources and/or dangerous features.
Highlight the locations.
B. Blueprint or drawing of home with bedroom of the individual with special needs
5. Attach a list of precautionary security measures that are in place at the person’s residence.
For example, if the windows are nailed shut or have bars on them, or if they are made of
Plexiglass or Lexan; if there are locks on all doors including interior doors; if there is a
locked gate around the property, etc. These are important details for emergency responders
to know ahead of time, so that they are prepared to handle the special safety measures when
they arrive on-scene.
Special Needs
Emergency Information Form
Operation Lifesaver ID #:
Home Phone Number:
Work Phone Number:
Physical Description
of Person Method of Communication
Name of Parent
or Guardian:
Home Phone:
Work Phone:
Cell Phone:
Describe any unique or special behaviors / characteristics for this individual
Describe best approach technique for responders to use with this individual
Describe any Sensory, Medical or Dietary issues for this individual
ID Wear: jewelry, tags, name on clothes, tattoos, etc.
List favorite places where this individual might be found
Eye Color:
Hair Color:
Non Verbal:
Sign Language
Picture Board
Written Word
Home Phone:
Work Phone:
Cell Phone:
Place Photo Here
Additional Emergency Contact Information: