Safety Alert Form

Dear Instructor:

I am a student enrolled in your class this semester.  In case of an emergency, I may need to have special assistance.  As the instructor of the class, I know that you have responsibility for the safety of all  your students during an emergency evacuation. The Disability Support Programs and Services office asked me to let you know that if there is an emergency, I will need the following type of help:

During evacuation drills and in real emergencies, I do not need to be moved to another floor level except under certain conditions. In general, it will be best for me to go to an outside location on the same level.

_______ I can walk, but I need at least one person to help me.

_______ I cannot walk, but can be pushed in my wheelchair.

_______If I must be evacuated to another floor,I cannot walk and will need to be

            carried. (This will require two strong persons who will need to use

            the interlocking arms/hands approach.)

_______I cannot walk, but I can be carried in my wheelchair. This will require the help

            of two strong persons.

_______ I cannot/may not hear alarms. Someone will need to make sure that I

  understand that an emergency exists. If I do not have an interpreter present,

             simple gestures should be fine, and/or a written note, (ie: "Fire-Follow Me!)"

Special Consideration: _____________________________________________________

________________________________________________________________________

________________________________________________________________________

_______I would like to meet with you for a few minutes at your convenience to talk about

            my special needs.

Thank You,_________________________