Cognitive Issues Alert – Northborough Police Department

This is a cooperative effort of the Northborough Police Department and the Northborough Council on Aging to assist caregivers of individual’s with dementia or cognitive issues.

The data provided is to be used to assist in the investigation of a person who is reported missing.

Please fill out the form below to provide the Northborough Police Department with necessary information to assist in the event of an emergency.

Click Here to view a pdf version of the fillable form and submit to:

NORTHBOROUGH POLICE DEPARTMENT
211 MAIN STREET
NORTHBOROUGH, MA 01532
C/O CHRISTOPHER CARLETON

"*" indicates required fields

Name of Person Submitting this Form*

Email of Person Submitting this Form*

Individuals Information

Name

First Last

Date of Birth

Address

Street Address City State ZIP Code

Does the individual live on their own or with someone?

Race

Height

Weight

Eye Color

Hair Color

Cognitive Issue/ Diagnosis

Identifying Marks

Tattoos, Scars, Prosthesis

If so, explain/describe

Does the individual attend a day car program?

If yes, where?

Individuals Physician

Physicians Phone #

Medications

Any additional physical problems

Does the Individual drive?

Yes

Does the Individual have access to a car?

Yes

If yes, please provide: Plate #, State, Make/Model, Year, Color

Does the individual carry Identification?

Yes

If yes, what?

Does the individual have particular habits?

Is the individual physically aggressive?

Hobbies and/or favorite locations

If previously reported missing where were they found?

Other Helpful Information?

Caregiver

Individual lives with:

Relationship to individual

Caregiver Email*

Phone*

Address

Contact #2 (Name)

Relationship to Individual

Contact #2 Email

Contact #2 Phone

Address

Contact #3 (Name)

Relationship to Individual

Contact #3 Email

Contact #3 Phone

Address

Contact #4 (Name)

Relationship to Individual

Contact #4 Email

Contact #4 Phone

Address