Putnam County Needs Registry Application
Date Completed
*
-
Month
-
Day
Year
Date
I am completing this form for
*
Myself
As a caregiver for the person listed
If Completing for someone else, please provide your name
*
First Name
Last Name
This is an
*
Initial Application
Update to Information
Back
Next
Application Information
Please provide your full legal name
*
First Name
Middle Name
Last Name
Please provide any alternate names, nicknames or alias (if applicable)
Date of Birth
*
-
Month
-
Day
Year
Date
Please provide a current photograph for identification records
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Residence Information
Are you a temporary or permanent resident of Putnam County?
Temporary
Permanent
Unknown at this time
Physical Street Address
*
Street Address
Street Address Line 2
City/Town/Village
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Current School District Attending
Type of Residence
Apartment
Townhouse
Private residence
Multi-family home
Group home
ICF
Other
If applicable, please provide your key location or door code
Are there any weapons in the home?
Yes
No
Back
Next
Contact Information
Do you have a phone
Yes
No
Type of Phone
House Phone (LANDLINE)
Mobile Phone
Work Phone
Other
Enter Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you use TTY?
Yes
No
If yes, is the above number for your TTY?
Yes
No
If your TTY Number is different, Please list
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have an email?
Yes
No
Email Address
*
example@example.com
Back
Next
Identifying Information
Gender
Male
Female
Transgender
Non-Binary
I do not wish to identify..
Other
Primary Languages
English
Spanish
Sign Language
Other
Height (In Feet)
Height (Inches)
Weight
Eye Color
Blue
Brown
Gray
Hazel
Green
Other
Hair Color
Brown
Blonde
Red
Black
Gray
Other
Complexion
Fair
Medium
Dark
Other
Do you wear any of the following? (check all that apply)
Glasses / Eye Protection
Contacts
Hearing Aids
Ear Protection
Doyou have any distinguishing physical characteristics? (i.e., scars, birthmarks,tattoos, etc.- check all that apply)
Scar
Birthmark
Tattoo
Other physical Characteristics?
Back
Next
Evacuation Information
Do you have access to transportation?
Yes
No
Rely on public transportation
Rely on transportation of someone else
If I need to evacuate, I will go to
Family
Friend
Assistive Facility
Shelter
Other
I have no place to go
Friend or Family Member Name
First Name
Last Name
Friend or Family Primary Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
I have arranged for someone to help me evacuate
Yes
No
I do not have a plan at this time
I need assistance with evacuating
Yes
No
If Yes, I have the following needs (Check all that apply)
I use a wheelchair.
I use a walker.
I use a cane or other adaptive equipment.
I can transfer independently.
I am bedridden and require evacuation / transport assistance.
I need more than one person to assist me.
Other
If you require assistance evacuating your home, what level of assistance do you need?
Standby supervision- I do not need physical assistance but may require verbal reminders.
Minimal assist/one person assist- I need minimal physical assistance with transfers and can weight-bear once up.
Two-person assist- I require more than minor physical assistance. I cannot transfer independently and/or I need equipment to transfer.
Total assist- I require full physical assistance for any transfers, standing or mobility. I cannot evacuate independently.
Other
I require the following equipment, that is not easily moved at the time of an emergency:
Oxygen
Ventilator
Other
Back
Next
Tell Us About Yourself and Your Needs
Do you have a service animal?
Yes
No
I am (Check all that apply):
Legally blind
Visually impaired
Deaf
Hard of hearing
Verbal
Non-verbal
Partially verbal
On the Autism spectrum
An elopement/wandering risk
A fall risk
Bedridden
Not Applicable
Other
I have sensitivity to the following (check all that apply):
Animals
Drones
Lights
Sound/loud noises
Sirens
Physical touch
Sudden movements
Not Applicable
Other
I have a typical response to pain.
Yes
No
If No, Please Describe.
Back
Next
Tell Us About Your Medical Needs
I wear identification (medical bracelet, necklace, ID card, tracking device) to alert someone of medical issues:
Yes
No
If yes, please list the identification/tracking application used and Application Account Number:
I am diagnosed with the following medical issue(s) (check all that apply):
Diabetes
Heart condition
Blood pressure issues
Seizure disorder
Not Applicable
Other
Is there anything you have a significant allergy to?
Yes
No
If yes, please list:
Do you carry an Epi-Pen or similar for this?
Yes
No
Do you have any implanted devices that would be important for responders to be aware of:
Yes
No
If yes, please select:
VNS
Pacemaker
Defibrillator
Other
Please list any medications taken for your needs:
Back
Next
Tell Us About Any Risks for Wandering or Elopement
Do you have a history of eloping, wandering, or becoming lost?
Yes
No
If yes, please list the most common locations where you can be found, should an incident like this occur (please describe, listing any favorite places.)
Do you have a history of eloping, wandering, or becoming lost near water?
Yes
No
If yes, please list the most common locations where you can be found, should an incident like this occur (please describe, listing any favorite places.)
Are you able to swim?
Yes
No
The Putnam County Sheriff’s Office is part of Project Lifesaver, which is a program designed to protect, and when needed, quickly locate individuals with cognitive disorders who are prone to wandering behaviors. Is this a program you would like to be involved in or like more information about?
Yes
No
The Putnam County Sheriff’s Office is also a part of the “are you okay?” safety program which targets vulnerable individuals who, in the event of crisis, are at risk for being left unattended or unassisted for long periods of time. Is this a program you would like to be involved in or like more information about?
Yes
No
Back
Next
Tell us about any disabilities you may have
I have (check all that apply):
A physical disability
An intellectual disability
A learning disability
Behavioral issues
Emotional issues
Dementia/Alzheimer’s
A seizure disorder
A speech impairment
Other
How do you communicate best (check all that apply)?
Independently- I am verbal and self-advocate.
I can answer basic questions about myself.
It takes me time to process questions and respond, but I can do so.
I repeat phrases I hear, but do not know how to answer on my own.
I need someone to advocate for me.
I have a communication device.
I use American Sign Language.
I use Picture Exchange Communication System (PECS)
Other
I can read.
Yes
No
I can write.
Yes
No
I can respond to my own name
Yes
No
In the event of an emergency, do you know how to contact 911 or emergency services?
Yes
No
I need help initiating.
I can provide my location to Emergency Services / 911
Yes
No
I can respond to commands or directions
Yes
No
Back
Next
Tell us about any behavioral history
Do you have a history of physical aggression?
Yes
No
If yes, what?
Hitting
Biting
Hair pulling
Scratching
Kicking
Banging head
Self-injurious behavior
Other
Do you have anything which triggers you, or causes you to become upset?
Yes
No
If yes, please describe.
Does deviation from routines cause you distress?
Yes
No
If Yes, Please describe
Do you ever engage in behaviors when you are anxious, upset, or nervous?
Yes
No
Please select all that apply during these times.
Rocking
Pacing
Repeating phrases
Making sounds
Avoiding social contact
Covering ears
Other
What do you find calming?
Use of sound (music, soothing noises, voices)
Use of touch (supportive, or something like a fidget)
Visual stimulation (on an electronic device)
Taste (Specific food or drink)
No extremes (no loud noises, yelling, sudden movements)
Specific phrases
Other
If Specific phases is selected, what specific phrases are calming / helpful?
If you left the home, or had to evacuate unexpectedly, would you be a danger to yourself or others?
Yes
No
If yes, please describe. (i.e. Would you be able to find your way back, would you enter another home without permission, etc.)
Do you know who to contact if you are feeling unsafe or emotionally unstable?
Yes
No
Back
Next
Tell us anything that would be important for others to know about you
Is there anything else that would be helpful for law enforcement/ first responders to know about you, that would help in a time of crisis?
Yes
No
If yes, please describe. (Please include favorite places, special interests, things, people, etc.)
Back
Next
Emergency Contact Information
Contact 1
Name
First Name
Last Name
Relationship
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Best Phone Number to be reached at
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Emergency Contact Information
Contact 2
Name
First Name
Last Name
Relationship
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Best Phone Number to be reached at
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Medical Emergency Contact Information
If a doctor needs to be called on your behalf in an emergency, please provide their information
Name
First Name
Last Name
Type of Doctor
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Best Phone Number to Reach
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
I, _________________________________have been informed that there is a Needs Registry for individuals with disabilities. This registry will be used to assist in evaluation, planning, and continuity of services in Putnam County, including the Office for Individuals with Disabilities and for first responders, including law enforcement and emergency services personnel in aiding people with disabilities.
Type your Full Name
I, _________________________________
(Guardian/Advocate/Representative)
Agree to have ___________________________ added to the needs registry.
(Applicantfor whom this Registry applies)
All information provided will be maintained confidentially and protected from further disclosure. I understand the information in the Registry will be used for collaborative planning purposes with other duly authorized agencies and service members in the County. I understand that I have the right to request removal from this registry and stop release of this information at any time.
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: