Special Concerns Information

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Logan’s Law (HB 631) went into effect on July 1, 2023, and provides a system for local governments to maintain a database with information to alert first responders that there are individuals in the home who may have special needs. This allows EMS, firefighters, and law enforcement to respond to situations at your home while considering any special concerns for those who may live there. Logan’s list, as the database is called, is completely optional. Families wishing to participate can complete the online form below.

Please correct the fields below:

Please correct the field(s) marked in red below:

City of Conyers

Police Department

Special Concerns Information

Logan's List

CHECK BOX IF INFORMATION CAN BE SHARED WITH ROCKDALE COUNTY EMERGENCY OPERATIONS FOR DISPATCH OF FIRE, LAW ENFORCEMENT, AND EMS SERVICES

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CHECK BOX IF INFORMATION CAN BE SHARED WITH ROCKDALE COUNTY EMERGENCY OPERATIONS FOR DISPATCH OF FIRE, LAW ENFORCEMENT, AND EMS SERVICES

	Yes	No
Selection	CHECK BOX IF INFORMATION CAN BE SHARED WITH ROCKDALE COUNTY EMERGENCY OPERATIONS FOR DISPATCH OF FIRE, LAW ENFORCEMENT, AND EMS SERVICES	CHECK BOX IF INFORMATION CAN BE SHARED WITH ROCKDALE COUNTY EMERGENCY OPERATIONS FOR DISPATCH OF FIRE, LAW ENFORCEMENT, AND EMS SERVICES

General Information About the Concerns Person

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General Information About the Concerns Person

Name:

Nickname:

Address:

Home Phone Number:ext.

Cellular Phone Number:ext.

Birthdate:

Race:

Gender:

Height:

Weight:

Hair color:

Eye color:

Employer/School Address(Only if in City of Conyers, Rockdale County):

Special concern or condition:

Please list any activations or triggers which may escalate an encounter. What actions should be avoided, if possible, by first responders?

Suggestions and techniques that can be taken to resolve a confrontation successfully:

Medications:

How does this medication affect actions, responses, senses, the potential for violence, etc. ?

This person is:

Sensitive to light

Likely to hide

Sensitive to touch

Likely to fight

Subject to seizures

Violent

Other If other, type text here.

Responsible Party Completing This Form

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Responsible Party Completing This Form

Name:

Relationship:

Address:

Cellular Phone Number:ext.

Secondary Telephone Number:ext.

Email Address

E-Signature:

Date:

Please check yes or no if the Emergency Contact Information is the same as above.

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Please check yes or no if the Emergency Contact Information is the same as above.

	Yes	No
Selection	Please check yes or no if the Emergency Contact Information is the same as above.	Please check yes or no if the Emergency Contact Information is the same as above.

Emergency Contact Information:

Emergency Contact Information:

Name:

Relationship:

Address:

Cellular Phone Number:ext.

Secondary Telephone Number:ext.

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Email Address