At Risk Individuals Alert (Alzheimer’s, Autistic Spectrum, etc)

2. The At Risk Individuals Alert is an initiative of the Fitchburg Police Department that allows members to
   voluntarily supply information that assists the Fitchburg Police to gain quick access to critical information
   in emergency situations. Please complete the following form and submit it with a current photograph.
   The form can be submitted below, via email OICWEB@fitchburgma.gov or printed and delivered to the
   Fitchburg Police Department located at 20 Elm Street. Once submitted, a member of the Fitchburg Police
   Department will reach out to the primary caregiver to confirm receipt of the registration. Once the
   information is verified, it will be secured by the Fitchburg Police Department and accessed accordingly.
   Please update the information and photograph on a regular basis (aging) or when changes occur. If
   additional information is needed, contact the Community Engagement Commander at 978.516.9367.

4. Basic Information
6. First Name*
7. Last Name*
8. Nickname
10. Date of Birth*
11. Age*
13. Address*
15. City*
16. State*
17. Zip Code*
21. Physical Description
23. Height*
24. Weight*
25. Sex*
27. Hair Color*
28. Eye Color*
29. Race*
31. Does the Person have the following:

    1. Glasses
    2. Dentures
    3. Hearing Aides

    1. Medical Jewelry
    2. Artifical Limbs
    3. Driver's License (Identification)
33. Birthmarks, Moles, Scars, Tattoos
37. Diagnosis and Medical History
39. Impairments*
41. Communication Level
43. Language(s) Spoken*
44. Language(s) Understood*
46. Responds to Verbal Commands, Name

    1. Yes
    2. No
48. Triggers
49. De-escalations
51. Wanderer
53. Physician's Name and Phone Number
54. Daycare / Program / School
56. Primary Caregiver Information
58. First Name*
59. Last Name*
61. Address*
63. City*
64. State*
65. Zip Code*
67. Personal Phone Number*
68. Work Phone Number*
69. Email*
71. Relationship*
73. Additional Caregiver / Emergency Contact
75. First Name
76. Last Name
78. Address
80. City
81. State
82. Zip Code
84. Personal Phone Number
85. Work Phone Number
86. Email
89. Relationship
93. Please share any other information that would be helpful*
95. Upload Photo*
Leave This Blank:


103. 1. Receive an email copy of this form.
104. Email address

     This field is not part of the form submission.

105. Submit Submit and Print

* indicates a required field