Emergency Evacuation Request

To be effective in the event of an emergency evacuation, NIACC must be able to identify and support those students with a disability who need assistance in order to evacuate safely.

A Personal Evacuation Plan will be developed in cooperation between the student, Disability Services Counselor, and other involved individuals. You will be contacted regarding this request.

General Information
Today's Date*
MM slash DD slash YYYY

Please enter today's date
Name*
First Last
Student ID*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email*
Disability Information
Functional Limitation(s)*
- Mobility
- Auditory
- Visual
- Other
If other, please list here.*
How does your disability affect your ability to evacuate during an emergency?*
Examples of things to consider:
1. Can you use stairs?
2. Are you limited in your use of latches?
3. Would you be able to hear an alarm?
4. Do you use a wheelchair, cane or guide dog to helpyou travel throughout the day?
Emergency Evacuation Request Affirmation*
- I affirm that the information contained in this form is true and accurate to the best of my knowledge. If any information changes, I will notify the Disability Services Office immediately.
Name
This field is for validation purposes and should be left unchanged.

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Emergency Evacuation Request

General Information

Disability Information