Family Safety Questionnaire

The Family Safety Questionnaire is a result of a partnership between community members and the Shaker Heights police and fire departments. The online questionnaire helps ensure that the City’s safety services have access to important information about community members with cognitive disorders, including dementia and autism spectrum disorder. This information can be critical in cases where affected individuals wander or are in a crisis situation.

What is the goal of this program?

To help ensure the safety of community members with cognitive disorders — including dementia and autism spectrum disorder — by providing our safety services with information to help identify and protect your family member in a crisis situation.

How can I participate?

An adult family member — or guardian — can complete and submit the Family Safety Questionnaire online. The information requested includes name, physical description, emergency contact information, triggers/behaviors, and other details helpful for our safety services.

What happens once I submit the form?

Once you submit the Family Safety Questionnaire, members of the City’s safety services will review the information to ensure it is complete. Next, the information will be forwarded to the Heights Hillcrest Communications Center (HHRC) — the City's dispatch center — for inclusion in its emergency response system. This information will then be available to safety services responding to a call for help or assistance at your address.

How will the information be kept current?

City staff will periodically reach out to the family member or guardian who submitted the questionnaire to ensure the information remains up to date. Community members are also encouraged to re-submit the form with updated information.