Missing Person Intake Form – Pennsylvania Emergency Response Center Inc.

Pre-screening

Name of person completing form *

First

Last

Are you the Missing Person's Immediate Family or Guardian? *

Are you currently receiving assistance from any other organizations *

Please list the names of any other organizations providing assistance

Unable to proceed at this time

The Pennsylvania Emergency Response Center services may only be requested by the Immediate Family or Law Enforcement. If you are Law Enforcement, please call us at (412) 857-4727 for assistance

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About You

Phone

Email *

Facebook

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About the Missing Person

Name *

First

Middle

Last

If no middle name, please put N/A

Date went missing *

State they are Missing From *

This will be the State that the missing person report was filed in

City they are Missing From

Date of Birth

Age Went Missing

Nicknames

Nickname

Height

Weight

Hair Color

Hair Style/Length

Eye Color

Do they wear Glasses or Contacts? *

No
Yes, Glasses
Yes, Contacts

Do they wear Braces *

No
Yes, traditional metal braces
Yes, Invisible Aligners (i.e Invisalign)

Do they have any Birthmarks or Scars? *

Please list/describe all Birthmarks or Scars

Do they have any Piercings or Tattoos

Please list/describe all Piercings or Tattoos

Do they have any other Distinguishing Features?

Please list/describe any other Distinguishing Features

Please list any medical issues

Addresses

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please list all known addresses for the missing person, in order of last occupancy

Please list any of the Missing Person's Social Media Usernames

Please provide the name(s) of the person(s) the missing person was last seen with

Please describe the circumstances surrounding the time they went missing

At least 48 hours prior

Please describe what the missing person was wearing when they went missing

What items did they take with them

Do they have a phone?

Phone

Do you have access to the missing person's phone records

Does the missing person have a vehicle

Please Provide the License Plate Number

Please provide a description of the vehicle

Please list the name(s) and contact information for any of the missing person's Best or Closest friend(s)

Is there any other information you would like to provide?

Boyfriend, Girlfriend, Places they like to hangout, etc.

Please provide pictures that may be used for poster creation and any other related files that may be helpful in locating your loved one.

Click or drag files to this area to upload. You can upload up to 4 files.

pdf, jpg, jpeg, and heic files only

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Law Enforcement Agency Handling the Case

Name of the Police Department *

Phone

Case Number

Lead Officer

Phone of Lead Officer (If Known)

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Agreement

I agree that all photos provided of my loved one may be used for the creation and distribution of a missing flyer and in other efforts to locate the missing person. I am also aware that these photos will be seen publicly while the person is missing and may continue to be seen after the person is found. I understand that any take down of missing flyers after location of the missing person is my responsibility. In addition, I agree that have disclosed any Organizations that we are receiving help from at this time. I also give full right to Pennsylvania Emergency Response Center Inc. to share information at their discretion as needed in any and all searches related to or in direct correlation to finding my loved one, such as but not limited to, locations of interest. Information that could be deemed sensitive shall remain confidential. At my request Pennsylvania Emergency Response Center Inc. will make every effort to remove posts of my loved ones’s missing poster, however I understand that this does not guarantee removal in entirety from the internet. I certify that I am the immediate family or guardian of the missing person in this form and have the legal right to request services for this person. providing my signature below and submitting this form, I certify that the above is true.

Signature *