In an emergency, I should be alerted by: (check all possible
options)
___ visual alarms, if building is equipped
___ physical contact
___ turning the lights on and off (flashing lights)
___ a written note explaining the emergency
___ gestures that indicate what is happening and what to do
___ other: _______________________________________
_______________________________________
To get to safety, I would need: (check all possible options)
___ a volunteer co-worker to escort and guide me to the nearest
evacuation route.
___ a volunteer co-worker to relay verbal instructions being given
through gesture or written
note.
___ a volunteer co-worker to relay environmental warnings and dangers.
___ other: _____________________________________________
Other instructions: ____________________________________________
____________________________________________
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From a First Floor Location:
In an emergency, I should be assisted by: (check all possible
options)
___ a volunteer co-worker to push my manual wheelchair.
___ a volunteer co-worker to clear any obstacles obstructing my path
to the nearest evacuation
route.
___ a volunteer co-worker to provide assistance while walking or
running.
___ a volunteer co-worker to assist opening doors.
___ a volunteer co-worker to push me in a chair on roller-wheels.
___ two volunteer co-workers to carry me in locked-arm position.
___ two or three volunteer co-workers to carry me in a sturdy
chair,
preferably one with arms.
___ other: ______________________________________________
Other instructions: _____________________________________________
_____________________________________________
_____________________________________________
From an Upper Floor Location:
In an emergency, I should be assisted by: (check all possible
options)
Ambulatory:
___ volunteer co-worker(s) to assist me using the stairs.
number of volunteers
needed: ____
___ other: ________________________________________
________________________________________
Non-Ambulatory:
___ two volunteer co-workers to carry me in locked-arm position.
___ If more than three
flights, a volunteer relay team in pairs.
___ two or three volunteer co-workers to carry me in a sturdy chair,
preferably one with arms.
___ If more than three
flights, a volunteer relay team in pairs.
___ two or three volunteer co-workers to carry me in my manual
wheelchair.
___ If more than three
flights, a volunteer relay team in pairs.
___ other: __________________________________________
__________________________________________
___ On a flight of stairs, I should be carried facing:
___ forward
___ backward
___ If a seatbelt is available, I should be secured with the belt before
transporting.
___ To transfer me from my wheelchair, volunteers should: (list
instructions)
______________________________________________________
______________________________________________________
______________________________________________________
___ Other instructions:
________________________________________
_______________________________________________________
_______________________________________________________
After-Care Instructions (following the evacuation): (list)
___________________________________________________________
___________________________________________________________
___________________________________________________________
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In an emergency, I should be assisted by: (check all
possible options)
___ an auditory alarm, if building is equipped.
___ a description of the emergency (the nature of the
emergency).
___ precise verbal instructions.
___ a volunteer co-worker to guide me by my taking his or her
elbow.
volunteers: give
verbal warning of upcoming steps
or other obstacles in the pathway.
___ a volunteer co-worker to lead the way to the nearest evacuation
route.
___ two volunteer co-workers to carry me in locked-arm position or
in a chair, if needed.
___ If more than three
flights of stairs, a relay team may be needed.
___ other: _________________________________________________
_________________________________________________
After-Evacuation Instructions:
___ reorient me to the new location.
___ offer guidance and assistance as needed.
___ other: _________________________________________________
_________________________________________________
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Additional Resources for Information:
Visit the following web sites for additional information and
guidelines on evacuation procedures.
Emergency
Evacuation Procedures For Employees with Disabilities (JAN)
Assisting People
with Disabilities in a Disaster (FEMA)
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