Emergency Evacuation Preparedness: Taking Responsibility For Your Safety A Guide For People with Disabilities and Other Activity Limitations

Will you need assistance in an emergency evacuation?

Do you experience any of the following conditions that could interfere with your ability to quickly evacuate a building?
Yes	No	Limitations that interfere with walking or using stairs (joint pain, mobility device user - wheelchair, canes, crutches, walker).
Yes	No	Reduced stamina, fatigue or tire easily (due to a variety of temporary or permanent conditions not limited to those on this list).
Yes	No	Respiratory (cardiac [heart] conditions, asthma, emphysema, or other symptoms triggered by stress, exertion, or exposure to small amounts of dust or smoke etc.).
Yes	No	Emotional, cognitive, thinking, or learning difficulties (may become confused when dealing with unfamiliar and unusual activity during an emergency, lose sense of direction, or may need emergency directions explained in simple steps or basic concepts).
Yes	No	Vision loss (may require assistance in learning the emergency evacuation routes or assistance in moving down stairs).
Yes	No	Hearing loss (may require modification to the standard way emergency announcements, notifications and instructions are provided).
Yes	No	Temporary limitations resulting from, but not limited to:
		Surgery,
		Accidents and injuries (sprains, broken bones),
		Pregnancy.
Yes	No	Do you rely on technology or medication which may not work in an emergency ( hearing aids, wheelchair, gas mask, elevator, lighting, sounds)?
Yes	No	Other:

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