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Building Evacuation Assistance Form

Voluntary Self-Identification

If you require any assistance to safely exit the building in the event of an emergency evacuation, please complete this form and state specifically what assistance will be needed.  This information will be kept confidential and used only by Campus Safety and police and fire officials responding to a building emergency.

In the event of an emergency evacuation, we ask that you go to the nearest area of rescue assistance, if possible, and press the emergency alarm button.  This will inform emergency officials of your location.

If you no longer require assistance or your assistance needs change, please submit an updated form at your earliest convenience.  Students should submit an updated class schedule each semester that assistance is needed.

(Please fill out the form completely before printing)

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If this is a temporary request, please provide a date when assistance will no longer be needed.
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By checking this box, you acknowledge that all of the information on this form is true. A checked box indicated your acceptance and signature.