Commonwealth of PA Emergency Evacuation Assistance Disclosure Form

If you wish to be identified as someone that needs assistance to evacuate your building or work location during any emergency, please complete this form.

This information will be kept confidential and will only be used to assist you during emergency situations. Do not include personal health information in this survey. You may be required to complete a new form as often as quarterly even if your status has not changed. This will ensure records are up to date.

You will receive an email to verify that your information was received. If you have questions or do not receive an email verification, please email Safety Services at ra-oasafety@pa.gov.

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* Name

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* Email (example: yourname@pa.gov)

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* Work Phone

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* Building Name

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* Building Address

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* Floor

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* Room Number

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* Is the need for assistance during evacuations permanent or temporary (examples: recent surgery, broken leg)?

Temporary

Permanent

If temporary has been selected please indicate for how long (example: 6/1/2018 to 7/1/2018)

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* Description of assistance needed

I cannot descend the stairs because I use a wheelchair or other mobility device.

I cannot descend the stairs unassisted.

I can descend the stairs slowly after others have cleared the stairway and will do so in an actual emergency.

Other (you will be contacted for details)

Commonwealth of PA Emergency Evacuation Assistance Disclosure Form

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* Name

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* Email (example: yourname@pa.gov)

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* Work Phone

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* Building Name

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* Building Address

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* Floor

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* Room Number

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* Is the need for assistance during evacuations permanent or temporary (examples: recent surgery, broken leg)?

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* Description of assistance needed

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* Supervisor's Name

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* Supervisor's Work Phone

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* Supervisor's Email (example: supervisor@pa.gov)