Special Needs Information Form

Be Prepared Before an Emergency Happens

When every second matters, having the right information ready can make all the difference.

At NRV 911, our dispatchers and first responders work quickly to understand what’s happening and provide the right help. But in situations involving individuals with special needs, critical details aren’t always easy to communicate in the moment — especially during high-stress emergencies.

The EFFORT (Special Needs Emergency Information Form) is designed to solve that problem before it ever begins. It allows you to securely share important information about a loved one in advance, so responders know exactly what to expect and how to respond.

This confidential registry gives dispatchers immediate context and equips first responders with guidance on communication methods, behaviors, medical needs, and the best approach for care. That means less confusion, faster understanding, and a safer experience for everyone involved.

If you live in Montgomery County, Blacksburg, Christiansburg, or are part of the Virginia Tech community, taking a few minutes to complete this form now can make a meaningful difference when it matters most.

EFFORT Form

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Special Needs Person Information
Project Lifesaver ID# (Optional)
Name*
First Last
Nickname or Preferred Name*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Month
Day
Year
Primary Phone*
Secondary Phone (Optional)
Physical Description of Person
Gender*
Race*
Race (Other) - Please Specify*
Age*
Height*
Weight (lbs)*
Eye Color*
Hair Color*
Method of Communication*
- Verbal
- Non-Verbal
Non-Verbal Methods of Communication*
- Sign Language
- Picture Board
- Written Words
Emergency Contact Information
Name of Parent or Guardian*
First Last
Address of Parent or Guardian*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Secondary Phone (Optional)
Additional Emergency Contact Information (Optional)
Additional Caregiver
First Last
Address
Street Address Address Line 2 City State ZIP Code
Primary Phone
Secondary Phone (Optional)
Additional Information (Optional)
Describe any unique or special behaviors or characteristics for this individual
Describe best approach for responders to use for this individual
Describe any sensory or medical needs for this individual
ID Wear: Jewelry, name on clothing, tattoos, etc
Photo Upload (Optional)
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB.
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Special Needs Information Form

Be Prepared Before an Emergency Happens

When every second matters, having the right information ready can make all the difference.

EFFORT Form

Special Needs Person Information

Physical Description of Person

Emergency Contact Information

Additional Emergency Contact Information (Optional)

Additional Information (Optional)