Project Safeguard

Project Safeguard is a project in partnership with the community and Salt Lake Valley Law Enforcement. This online program promotes communication and gives police quick access to important information about a person who displays a tendency to wander; such as Autism, Dementia or other disability with similar tendencies. This program provides information that is critical for law enforcement prior to an officer's arrival at a scene and/or prior to contacting an individual with disabilities. Rapid access to information such as their name, birthday, physical description, emergency contact information, known triggers and behaviors etc. will help Officers during their initial response. Please share all information you feel comfortable providing. This form should be filled out yearly to insure accurate information is available for first responders. You will receive a notification at the end of each year to refresh your information.

PERSON COMPLETING THIS FORM

PERSON COMPLETING THIS FORM

Name - Person Completing Form

Phone

Phone

Email

Relationship to Person with Disability

Submission Type

Mark if this is a New Entry or Renewal

New Entry

Renewal

PERSON WITH DISABILITY INFORMATION

PERSON WITH DISABILITY INFORMATION

First Name

Last Name

Date of Birth

Race

Gender

Female

Male

Height

Weight

Hair Color

Eye Color

Identifying Features

Scars, Birthmarks, Tattoos, other Identifying Features

Upload a current photograph that only has the person you are submitting for in the picture.

Drop your files here

DISABILITY INFORMATION

DISABILITY INFORMATION

Primary Diagnosis

Co-Existing Diagnosis

Mark NA if not applicable

Communication Method

Verbal

Non-Verbal

Describe if Non Verbal

Mark NA if not applicable

Will They Respond To Their Name Being Called

Yes

No

RESIDENCE INFORMATION

RESIDENCE INFORMATION

Home Address

City

State

Phone

Phone

Weapons in the Home?

Yes

No

Weapons Properly Secured?

Yes

No

Not Applicable

AUTISTIC CHARACTERISTICS

AUTISTIC CHARACTERISTICS

Complete this section if person with disability is Autistic.

Sensory Issues

Seekers

Sensory Avoidant

Touch

Seekers

Sensory Avoidant

Sounds

Seekers

Sensory Avoidant

Bright Lights

Seekers

Sensory Avoidant

Stimming Behavior

Mark NA if not applicable

DISABILITY CHARACTARISTICS

DISABILITY CHARACTARISTICS

Process Delays

Yes

No

Fears

Mark NA if not applicable

Dislikes/ Triggers

Mark NA if not applicable

Favorite Objects /Topics

Pre-Meltdown Signs

Mark NA if not applicable

Meltdown Behavior

Mark NA if not applicable

Calming Strategies That Work

Mark NA if not applicable

Prior Contact With Police

Mark NA if not applicable

Alcohol/ Drug Issues

Yes

No

Does the Family Have a Crisis Plan

Yes

No

WANDERING

WANDERING

Prior Wandering Incident

Yes

No

If Prone To Wandering, Where Have They Been Found

Mark NA if not applicable

Closest Water To Residence

Mark NA if not applicable

List All Lakes, Ponds, Streams, Pools, Etc

Mark NA if not applicable

Favorite Hiding Places At Home

Mark NA if not applicable

Favorite Hiding Places in Neighborhood/ Community

Mark NA if not applicable

SCHOOL INFORMATION

SCHOOL INFORMATION

School Name

Mark NA if not applicable

Grade

Mark NA if not applicable

School Address

Mark NA if not applicable

School Contact Name

Mark NA if not applicable

School Contact Phone

Mark NA if not applicable

Bus Use

School Bus

UTA Bus

None

WORK INFORMATION

WORK INFORMATION

Work Name

Mark NA if not applicable

Work Address

Mark NA if not applicable

Work Contact Name

Mark NA if not applicable

Work Contact Phone

Mark NA if not applicable

PRIMARY GUARDIAN/CARETAKER INFORMATION

PRIMARY GUARDIAN/CARETAKER INFORMATION

Name

Relationship

Primary Phone

Phone

Secondary Phone

Mark NA if not applicable

Phone

Place of Work

Mark NA if not applicable

Work Address

Mark NA if not applicable

SECONDARY GUARDIAN/CARETAKER INFORMATION

SECONDARY GUARDIAN/CARETAKER INFORMATION

Name

Relationship

Primary Phone

Phone

Secondary Phone

Mark NA if not applicable

Phone

Place of Work

Mark NA if not applicable

Work Address

Mark NA if not applicable

PRIMARY EMERGENCY CONTACT INFORMATION

PRIMARY EMERGENCY CONTACT INFORMATION

Other than previously identified Guardians

Name

Relationship

Primary Phone

Phone

Secondary Phone

Mark NA if not applicable

Phone

Address

VEHICLE INFORMATION

VEHICLE INFORMATION

Vehicle 1 Make

Vehicle 1 Model

Vehicle 1 Year

Vehicle 2 Make

Vehicle 2 Model

Vehicle 2 Year

ADDITIONAL INFORMATION

ADDITIONAL INFORMATION

Add any additional information you would like us to know.

RELEASE OF INFORMATION

RELEASE OF INFORMATION

RELEASE OF INFORMATION

I, hereby give my permission for any first responder agency (including but not limited to police, fire/rescue/EMS/911 dispatch center, search and rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation. By clicking the Release of Information box and typing your full name in the box below, you are agreeing to the release terms posted above.

RELEASE OF INFORMATION

Release of Information Full Name

By clicking the Release of Information box and typing your full name in the box below, you are agreeing to the release terms posted above.

Problems with Form Submission

Problems with Form Submission

Please contact Danie Bills - DBills@UnifiedPoliceUT.gov if your are having trouble submitting this form.

Send me a copy of my responses