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Appendix C:

Sample employee emergency response information template

Instructions

Use the information collected in the employee emergency information worksheet to create individualized emergency responses for each employee with a disability. Feel free to modify the form if an employee needs different types of accommodations for different types of emergencies.

All information in this document is confidential and will only be shared with the employee’s consent.

Individualized Workplace Emergency Response Information for:

Name:

Department:

 

Emergency Contact Information

Name:
Telephone:	Email:
Mobile Phone:
Relationship:

 

Work Location

(Repeat for other work locations)

Address:
Floor:	Room Name/Number

 

Emergency Alerts

[Name of employee] will be informed of an emergency situation by:

Existing alarm system:  ___

Pager device:  ___

Visual alarm system:  ___

Co-worker:  ___

Other [specify]:  ___

Assistance Methods

List types of assistance (e.g. staff assistance, transfer instructions, etc.)

 

Equipment provided

List any devices, where they are stored, and how to use them.

 

Evacuation Route and Procedure

Provide a step-by-step description, beginning from the first sign of an emergency.

 

Alternate Evacuation Route

 

Emergency Support Staff

The following people have been designated to help [employee name] in an emergency.

Name	Location and/or Contact Information	Type of Assistance

 

Consent to share individualized emergency response information

I [Employee Name] give consent to [Name of Organization] sharing this individualized emergency response information with the individuals listed above, who have been designated to help me in an emergency.

Signature:

Date:

Form completed by:
[Manager]

Date:

Form reviewed by:
[Employee]

Date:

Next review date: