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U.S. Department of Health and Human Services
Indian Health Manual

Circular Exhibit 03-01-C

DISABLED EMPLOYEE EMERGENCY EVACUATION QUESTIONNAIRE

The Designated Official is responsible for alerting the fire department of the location of all disabled personnel in the Reyes Building or Twinbrook Metro Plaza (TMP).  It is critical for the Designated Official to know the location of all individuals with permanent and/or temporary disabilities who require assistance to exit either building in the event of an emergency evacuation.  The information you provide on this form will be kept confidential and will be used by the Designated Official only for the purpose stated above and to comply with the requirements of this Circular and other Federal requirements.

Evacuation Assistants (if requested) will be provided to assist disabled employees.

The fire department will use the elevators, if safe to do so, or the stairwells to evacuate all personnel with disabilities.  In an emergency situation, any disabled employee who cannot negotiate the stairs is to stay with the Evacuation Assistant in the stairwell (on the landing if possible) in preparation for evacuation by authorized personnel (fire department).

NOTE:  Stairwells are among the safest places to be during an emergency in the building.  They are constructed to provide 11/2 hours of fire protection to people who remain there.  An emergency generator, which provides lighting in the event of power outages, will provide enough electricity to keep the stairwell lights on.  The elevators will not be used, except by fire department or rescue personnel, for the purpose of evacuating disabled personnel from the building.

Name (print) and signature: _________________________________________________________________________

Room Number:____________________Phone Number:______________________

E-mail address:________________________________________________

Evacuation Assistant (if known):________________________________

  1. Is your disability permanent or temporary?___________________________________
  2. If temporary, how long do you expect to be disabled?__________________________
  3. Are you visually, hearing, or mobility impaired?_______________________________
  4. Do you need an Evacuation Assistant to ensure that you reach an area of refuge?
    (Check one)______________ Yes ____________No

    Please return the completed form to your supervisor or to the Floor Coordinator for your floor.

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