At-Risk Resident Questionnaire

Welcome to the Randolph Police Department’s At-Risk Resident Registry. This voluntary program helps our department provide rapid, specialized assistance to vulnerable community members including those with dementia, autism, or critical medical needs during an emergency. By securely sharing information such as physical descriptions, communication preferences, and favorite wandering locations, you ensure that first responders can quickly locate your loved one and approach them with the right care and sensitivity. All submitted details are kept strictly confidential and are only accessed by public safety dispatchers and officers in the field when an emergency or missing person report is active.

Name(Required)

First Last

Date of Birth(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender(Required)

Current School/Day Program (if applicable)

Home Phone Number

Cellphone Number

Race(Required)

Height(Required)

Weight(Required)

Hair Color(Required)

Eye Color(Required)

Primary Language(Required)

BEHAVIORAL, COMMUNICATION, AND SENSORY PROFILES: Is the person verbal or non-verbal? Do they use sign language, an iPad/AAC device, or picture boards? How do they respond to direct questions or commands?(Required)

TRIGGERS, DE-ESCALATION TECHNIQUES & HIGHLY MOTIVATING ITEMS: Do sirens, flashing lights, loud voices, or certain words cause severe distress? What is the best way to calm the person down (e.g., speaking softly, giving them physical space, mentioning a favorite topic, are there certain items that might motivate compliance)?(Required)

CHALLENGING BEHAVIORS: Does the resident have any challenging behaviors? Please include any indicators or warning signs the resident might display prior to engaging in challenging behavior.

WANDERING PATTERNS & ATTRACTIONS: Are they drawn to specific, dangerous environments like bodies of water (lakes, pools), trains, bright lights, or high places? Do they have a history of hiding in thick brush or small spaces? For people with dementia: Are there specific places they used to work, live, or frequent decades ago? (e.g., They may be trying to “go to work” or “go home” to their childhood street).

Other information that you feel officers should be aware of. (This may include but is not limited to medical history and or life-saving / behavior-altering medications the resident is required to take):

Emergency Contact Information

EMERGENCY CONTACT #1 – Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to At-Risk Resident(Required)

EMERGENCY CONTACT #2 – Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to At-Risk Resident

Upload a Recent Photograph of the At-Risk Resident

Max. file size: 256 MB.

At-Risk Resident Questionnaire

Emergency Contact Information

FOR EMERGENCIES 9-1-1