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Departmental Guidelines on Emergency Preparedness and Individuals with Disabilities

The U.S. Department of Transportation (DOT) is committed to providing emergency preparedness as an essential activity in meeting the needs of all people at its facilities, including people with disabilities and other medical conditions. Under Section 501 of the Rehabilitation Act, as amended (29 U.S.C. 791), and implementing regulations, the Department has a responsibility to provide adequate hiring, placement, and advancement opportunities for individuals with disabilities and reasonable accommodation in the workplace. The Department also has a responsibility under Section 504 of the Act (29 U.S.C. 794), to ensure that people with disabilities, including employees, job applicants and members of the public, are not excluded from or discriminated against under any programs or activities that the Department conducts. Accordingly, when emergency preparedness activities are undertaken in DOT occupied facilities, the Department must consider and provide for the needs of people with disabilities.

Given the terrorist attacks against the United States on September 11, 2001, the Department must take even more seriously its obligation to safeguard its employees, customers, and the public. Employees and others with disabilities should not feel any more vulnerable in the DOT work environment than non-disabled co-workers and visitors. The special needs of people with disabilities must be addressed as an enduring part of emergency preparedness at the Department.

The Heads of Secretarial offices and Operating Administrations shall be responsible for:

  • ensuring that emergency preparedness planning, procedures, and other activities undertaken in DOT occupied facilities address the needs of people with disabilities;
  • providing DOT employees with disabilities and organizations representing DOT employees with disabilities the opportunity to participate in the development of emergency preparedness procedures, including procedures for evacuation and shelter-in-place; and
  • ensuring that emergency communication plans are used to effectively communicate emergency plans and procedures for facilities to the Department's diverse workforce, including people with disabilities. Communication plans shall be available in necessary alternate formats.

Every member of the DOT workforce, including contractors, has a role in an emergency situation. Managers, supervisors, emergency planning team members (security, facility, safety and health officials, and responders), volunteers (fire wardens and buddies), contracting officers, and hosts of visitors must know their respective roles. We must also assume responsibility for our own planning and safety in an emergency, as well as working effectively with emergency planning officials.

I am pleased to provide the U.S. Department of Transportation guidelines entitled "Emergency Preparedness for People with Disabilities" which provides answers to basic questions about emergency preparedness and the needs of people with disabilities in DOT. These guidelines also list references to websites offering more questions and answers and "how-to" program information.

Within 90 days from the date of this memorandum, the Heads of Secretarial offices and Operating Administrations (OAs) shall review emergency planning efforts for their organizations and report their findings to the Assistant Secretary for Administration. The report must state: 1) whether or not the responsibilities identified herein are being met; 2) what actions have been taken or are contemplated to meet these responsibilities; 3) the timeframes within which such actions will be undertaken; and 4) the name of a key official in your organization with overall responsibility for emergency planning who will focus on the needs of people with disabilities.

The safe and efficient egress of individuals in DOT facilities is of paramount concern to the Department. Therefore, I would appreciate your personal attention to this important matter. The DOT Disability Resource Center is available as a technical resource to assist Secretarial offices and OAs.

U. S. Department of Transportation
Emergency Preparedness Guidelines for People with Disabilities

I. Introduction

The U.S. Department of Transportation (DOT) is obligated to ensure the safety of its employees, contractors, job candidates, members of the public, and other persons in any DOT facility. This document provides guidance, in a Q and A format, on emergency preparedness in DOT facilities for people with disabilities and certain other medical conditions. Each DOT Operating Administration (OA) and Secretarial Office should develop emergency preparedness plans for people with disabilities (plan). This plan must take into consideration the new variety of threats, including terrorism, bioterrorism, and spills of hazardous chemicals, as well as traditional threats, such as explosions, severe weather and fire. The hallmarks for the effectiveness of this plan include speed of actual implementation, practice, feedback and dialogue, flexibility, oversight, monitoring, and evaluation. All of the people who use DOT facilities, including people with disabilities, must be actively involved in preparations for emergencies.

The potential for emergencies or accidents that could have a serious impact, including injuries or death to employees and others in its facilities, exists in every organization. Planning for emergencies is critical to minimize adverse consequences. The most effective emergency evacuation plan is one that is designed in advance, created with the assistance of those involved, practiced and evaluated for effectiveness.

The primary objective of an emergency evacuation plan is the protection from injury and preservation of human life. Evacuation of personnel is only one component of a more comprehensive plan, variably known as a contingency plan, disaster response plan, crisis management plan, or emergency plan. This comprehensive plan anticipates any foreseeable physical dangers from naturally occurring or man-made threats.

A list of Internet resources on emergency preparedness for people with disabilities is attached to this document (Attachment I).

II. Roles and Responsibilities

Who bears responsibility under this plan?

Everyone connected with DOT bears some responsibility under this plan. Top management has oversight. Supervisors are responsible for the workplace well-being of their employees. Persons with disabilities have responsibility for their own safety contingency planning and for disclosing necessary information to the appropriate agency representatives. Safety personnel have the duties assigned to them under emergency planning such as 1) performing risk analysis to identify possible emergency scenarios involving people with disabilities; and 2) conducting employee training and testing under simulated conditions.

A strategy should be developed to cope with each hazard identified in the risk analysis. The strategy should address prevention of loss of life and of injury. Security staff must be knowledgeable and helpful to all in situations involving safety and security. Facilities management staff has responsibilities for lowering and removing barriers to people with disabilities. See Attachment II for a discussion of effective communication techniques with individuals with disabilities. Where questions exist as to responsibilities, solutions should be developed and memorialized so that responsibilities are clear, distinct, and unquestioned, with management making the final decision in the interests of all. The Department expects all involved to carry out these responsibilities in such a way as to ensure the safety and security of all.

What are the roles and responsibilities of supervisors and managers to work collaboratively with their employees with disabilities or certain medical conditions to develop individualized emergency preparedness strategies?

If an employee with a disability has identified himself or herself as an individual with disabilities and requested assistance in advance, then prior to and during an emergency, that employee's managers are responsible for working with the employee to understand exactly what kind of assistance is required and ensuring that such assistance is deployed during an emergency. Also, if employees with disabilities have difficulty recruiting evacuation buddies, supervisors and managers are responsible to assist in the recruitment. Evacuation buddies should work near the disabled employee so that they can respond quickly during an emergency. The subject of buddies is covered in more detail in Attachment III.

What should employees do in case of an emergency and what contingency plans should be made by people with disabilities or certain other medical conditions?

All employees and contractors must work in partnership with the Department to ensure a safe and appropriate response to an emergency. Employees and contractors must fully understand emergency preparedness plans. They should know how to safely evacuate the facility and how to respond to a shelter-in-place emergency. Employees with disabilities who need assistance during an emergency must inform the Department of their needs, including exactly what kind of assistance is required. Additionally, employees with disabilities are encouraged to set up a buddy system to support the emergency preparedness plan. For example, a coworker could operate an evacuation chair or help an individual with a vision impairment to walk down stairs. If any employee has difficulty in setting up a buddy system, management is responsible for providing assistance.

See Attachment III for additional information on buddy systems.

In order to assist in efficient evacuation, employees should take the opportunity to familiarize themselves with DOT buildings. It is important that they, to the greatest extent feasible, locate the most readily available telephones, horizontal exits and ramps, exit signs, enclosed stairwells (to determine whether landings are large enough), and rooms that would make good areas of refuge.

All employees should have a contingency plan that ensures their continued safety during an emergency. For example, if a DOT facility is evacuated and is not immediately able to be reentered, employees are responsible for their own transportation home. Employees with disabilities, too, should have systems in place to ensure their transportation home in case the workplace remains unusable. In situations where normal supportive transportation such as paratransit is not available owing to the nature of the emergency, DOT will make reasonable efforts to ensure that its employees are not stranded without appropriate care.

What is the role of the emergency warden in regard to people with disabilities and certain other medical conditions? How should such personnel be trained?

The emergency wardens are responsible for ensuring that all facility occupants are directed to the fastest and safest way out of the facility during an evacuation. Wardens must also be aware of the needs of people with disabilities and certain other medical conditions and must follow all appropriate protocols. Training on the safe evacuation of people with disabilities and certain other medical conditions is available from the DOT Disability Resource Center.

A typical evacuation procedure for employees with disabilities might be to direct them to the nearest manually controlled elevator for evacuation by a member of the emergency warden team. Wardens should be instructed to allow all people who ask to be evacuated via the elevator to do so if they so desire, even if they have no visible disability or medical condition.

During selective evacuations (evacuations where only the alarm floor and the floors directly above and below it are evacuated), persons with disabilities may be relocated to a nonalarm floor with other occupants rather than being taken to the ground floor. This is to protect persons with disabilities from undue exposure to outside weather conditions or from being stranded when a safe relocation floor is available within the building.

In the event that elevators become unusable during an emergency, the facility managers should plan alternatives for evacuating workers with disabilities. Numerous models of evacuation chairs are commercially available that enable disabled workers to be evacuated down stairwells and safely transported out of buildings. Because the evacuation devices require specialized training, it is important to instruct all emergency wardens, evacuation buddies, and people with disabilities before they have to use the devices in a real emergency.

How do we address emergency planning for visitors and contractors with a disability or certain other medical conditions who may be in a DOT building when an emergency occurs?

When employees are hosting visitors who may have a disability or other medical condition, the host employee has the responsibility for helping to ensure the visitors' safety during emergencies. Since the host employee is most familiar with the building's layout and emergency plans, it is recommended that the host employee accompany and help visitors with disabilities or certain other medical conditions during emergencies.

Emergency wardens are responsible for ensuring the safe evacuation of all facility occupants, including visitors and contractors with disabilities. Emergency wardens must be trained in how to communicate with and safely evacuate people with disabilities. Training is available from the DOT Disability Resource Center.

III. Emergency Information Management

Is it appropriate to request medical and other information to assist an individual with a disability in an emergency?

DOT is permitted to ask employees to self-identify and to indicate if assistance will be needed during an emergency under the following circumstances:

1) After making a job offer but before employment begins

2) By means of periodic surveys of all current employees, as long as DOT makes it clear that self-identification is voluntary and explains the purpose for requesting the information

3) By asking employees with known disabilities whether they will require assistance in an emergency.

DOT will not assume, however, that everyone with an obvious disability will need assistance during an evacuation or other emergency. For example, many people who are blind may prefer to walk down stairs unassisted, along with other employees. People with disabilities generally are in the best position to assess and make known their particular needs.

DOT will inform all people who are asked about their possible need for emergency assistance that the information they provide will be kept confidential and shared only with people who have responsibilities under the emergency preparedness plan. Since DOT may ask people who indicate a need for assistance to describe the type of help they think will be needed, a tool has been developed to standardize the information requested. Attachment IV is the tool.

For example, DOT may need to know whether someone who uses a wheelchair because of mobility limitations is able to walk independently, with or without the use of crutches or a cane, or if an individual will need any special medication, equipment, or device (e.g., a carrier strap for an assisted wheelchair or a mask because of a respiratory condition). DOT is entitled only to the information necessary to provide assistance. In most instances, it will be unnecessary for DOT to know the details of an individual's medical condition.

The Rehabilitation Act of 1973, as amended, requires that DOT programs and activities be nondiscriminatory and accessible. It also requires, as amended, that medical information about applicants and employees be kept confidential, except for that provided to first responders and first-aid and safety personnel. Thus, DOT may share information about the type of assistance an individual needs with medical professionals, emergency coordinators, floor captains, colleagues who have volunteered to act as buddies, building security officers who need to confirm that everyone has been evacuated, and other nonmedical personnel who are responsible for ensuring emergency preparedness under DOT's emergency preparedness plan.

Some examples of people who do not fit the legal definition of a person with a disability, but who may need assistance or special planning for emergencies include the elderly, pregnant women, and people who are obese. There may be people with temporary or episodic needs. In addition, during the course of the actual emergency, it is possible that other people will become disabled due to injuries, heart attack, respiratory crisis, stress, etc. When that happens, preparations, communications, and equipment specified in this plan will be useful and necessary.

Maintaining lists of employees and equipment

Appropriate management, safety, and security personnel must ensure that a list is maintained of persons who have notified facility staff that they have a disability or some other medical condition and will require special assistance in an emergency. The list must include the unit, office, or room number location that the person occupies in the building, as well as telephone numbers and emergency pagers. The list must be provided to fire and rescue personnel and other first responders so that they can be sure that all endangered employees are safe. A key element of emergency planning is working in advance with fire and rescue personnel and other likely first responders so that they will be familiar with the needs of DOT's employees with disabilities.

The plan must identify the location and type of any evacuation-assistance devices or assistive technologies that are in the building and where they are stored.

IV. Communication and Planning

What emergency communication plans are required for ensuring that people with disabilities and certain other medical conditions receive all emergency information?

A written communication plan for people with disabilities or certain other medical conditions is required. The plan needs to include methods for communicating emergency information to all employees. Emergency preparedness information should be communicated to new employees during orientation and training. Current employees should receive updates and reminders on emergency evacuation procedures and policies. All emergency preparedness plans should be made available in alternative formats (e.g., electronic format, large print, or Braille).

All actions in preparation for and during an emergency require excellent, speedy, and reliable communication. Communications must be effective and understandable, use redundant channels, be directed to people who need to act, and include feedback and dialogue. To ensure that people with certain sensory and cognitive disabilities (e.g., hearing, visual, or developmental disabilities) are sufficiently aware of emergency preparedness procedures, alternative communication mechanisms must be used where necessary. For example, emergency preparedness plans should be available in electronic format, large print, and Braille and provided to people who need them. Also, if a particular DOT facility is not equipped with flashing strobe fire alarms, it may be necessary to purchase vibrating text message pagers to inform deaf employees of an emergency. The DOT Disability Resource Center should be contacted to assist in identifying and acquiring appropriate communication devices for DOT employees. However, communication mechanisms must be established with all people who may be in the building, regardless of whether they are employees, contractors, or visitors. It may be necessary to use either text displays (television monitors or scrolling text signs) located throughout the building or portable devices (tactile or vibrating pagers), which have been utilized effectively. DOT employs a wide range of people. People with mental impairments may become confused when challenged with the unusual activity during an emergency, may lose their sense of direction, and may require having emergency directions presented as simplified steps or basic concepts.

Emergency alarms must be distinctive and easily recognized by all employees. The alarms must be able to be heard, seen, or otherwise perceived by everyone in the workplace.

During an actual emergency, continuous information must be provided to people with disabilities, as effectively as it is provided to other people in DOT facilities.

What procedures must be in place to ensure that people with disabilities and certain other medical conditions can report an emergency if they are the first to become aware of it?

Agency officials must ensure that emergency fire alarms are accessible to people who use wheelchairs, are short statured, or are blind, and that instructions for emergency alarms are accessible to people who are blind. Emergency telephone numbers also should be made accessible to people with hearing disabilities by installing an emergency TTY line or some other accessible approach. In regard to manual-pull fire alarms, facility managers should also consider that not all people possess the strength and/or dexterity to operate some of the manual-pull-station devices (e.g., people with arthritis or quadriplegia).

How should one plan for an emergency that occurs before or after core business hours?

Each employee and user of the building should perform individual planning for safe evacuation during nonbusiness hours, when fire wardens are unlikely to be available. All employees, including employees with disabilities, should have at least two escape routes from their offices. Additionally, employees with disabilities are strongly encouraged to have nonbusiness-hour buddies for assistance during an emergency. It is particularly important for security personnel to be familiar with this plan and with persons with disabilities who use DOT facilities after normal business hours. To maximize safety during non-business hours, the individual with a disability should alert building security upon entering the building. Someone will then be ready to search for and assist the individual to safety, if needed. Managers should ensure that shift workers and others who work on the premises outside normal hours, such as cleaners, are included in the agency emergency evaluation plan. If there are employees whose knowledge of English may be limited, training should be given in a way that they can understand. Non-English-speakers and staff who have poor reading skills should be considered when written instructions are prepared.

What strategies should be in place for conducting practice drills for people with disabilities or certain other medical conditions?

Effective response to emergencies requires preparation and drills in as realistic a manner as possible. This preparation includes assembly of individual safety kits and medicines, use of actual equipment, and use of actual exit routes. Furthermore, people with disabilities and certain other medical conditions should be provided the opportunity to have individual emergency drills with safety personnel, separate from the routine emergency drills, if any individual so requests. Facility and security personnel bear a particular responsibility to make certain that exit routes are unobstructed and to otherwise facilitate such drills. No drill should endanger life safety.

Facility and security personnel should treat individual and group drills as an opportunity to observe procedures and practices and to obtain feedback on how to improve evacuation strategies and tactics. Employee organizations that represent employees with disabilities may wish to schedule group drills to ensure that their members are prepared for an emergency. It will be useful to hold a critique session after each drill with the participants. If difficulties are discovered by means of the drills, persons with disabilities should be provided with alternative methods of evacuation.

Practice evacuations should not be voluntary. The people who might otherwise opt out of the exercise may in fact be the ones who will pose the greatest challenges. Practice evacuations with less than the full complement of people in the building can also give a false timeframe for evacuating the building.

V. Facilities

Modifications that may be required to facilities

Employees with disabilities and others may request pathway marking systems and other special signage to assist them in evacuation. Facility management and staff should make every effort to accommodate such requests.

Vl. Training

All workers, including workers with disabilities or certain other medical conditions, must understand the workplace emergency plans. Employers are required to train employees whenever:

  • New emergency plans are developed;
  • Employees are assigned initially to a job;
  • Employees' responsibilities within the plan change; or
  • The plan is changed.

DOT is also required to designate employees to assist in the safe and orderly evacuation of the workplace. Emergency wardens must receive training in emergency procedures and completely understand their roles during emergencies. People who need additional assistance with their building's emergency procedures should contact their employing agency or the facility's safety officer.

Since the Department also has many contractors working within DOT facilities, it is extremely important to make sure that contractors are informed of workplace emergency plans. The DOT offices responsible for issuing contracts should ensure that emergency plans are shared and understood by the contractors working within DOT's facilities. Ideally, all contractors should develop their own emergency action plans that mirror the overall DOT plans for the building. However, contractors' emergency plans may have specific differences, such as designated meeting places or internal emergency wardens.

Attachment I: Web Resources on Emergency Preparedness for People With Disabilities

Emergency Preparedness Guide from the National Organization on Disability 

Compelled by the attacks of September 11, 2001, the National Organization on Disability (NOD) launched the Emergency Preparedness Initiative (EPI) to ensure that emergency managers would address disability concerns and that people with disabilities were included in the emergency planning process. NOD seeks to increase communication and cooperation between emergency managers and the disability community and to educate people with disabilities about what they can do to be prepared.

FEMA Emergency Procedures for People With Disabilities

This booklet offers ideas and solutions for dealing with challenges to the safety needs of people with disabilities.

Fire Risks for the Mobility Impaired

Fire Risks for the Blind or Visually Impaired

Fire Risks for the Deaf or Hard of Hearing

U.S. Access Board
The U.S. Access Board hosts a Web area that includes more resources for the emergency evacuation of people with disabilities.

Job Accommodations Network Emergency Preparedness Guidance 
This publication is intended to provide an overview of emergency procedures for employees with disabilities.

The National Center on Emergency Planning for People With Disabilities

The National Center on Emergency Planning for People with Disabilities provides resources to assist local emergency planning organizations (both public and private) to plan for assisting people who need specialized communications, transportation, and medical supports.

Attachment II: Tips on Interacting With People With Disabilities

Below are detailed pointers for interacting with people with various types of disabilities during emergency situations. This information comes from The Center for Disability Issues and the Health Professions (CDIHP) at Western University of Health Science's guidance on disaster preparedness guidance for people with disabilities. Suiting the content and type of message to the receiver will accomplish the best results. The method is also important. Effective communication will take place only when the special needs of the recipient of the message are taken into consideration. Since in an emergency time is of the essence, giving information in the most efficient way for the person you are trying to warn or to help will be not only critical but lifesaving.

Vision Impairments

When assisting persons with vision impairments, there are some basic rules to follow in order to be effective:

  • Announce your presence; speak out when entering the work area.
  • Speak naturally and directly to the individual and NOT through a third party. Do not shout.
  • Don't be afraid to use words like "see," "look," or "blind."
  • Offer assistance but let the person explain what help is needed.
  • Describe the action to be taken in advance.
  • Let the individual grasp your arm or shoulder lightly for guidance. He/she may choose to walk slightly behind you to gauge your body reactions to obstacles; be sure to mention stairs, doorways, narrow passages, ramps, etc.
  • When guiding the person to a seat, place his or her hand on the back of the chair.
  • If leading several people with visual impairments at the same time, ask them to hold each other's hands.
  • After exiting the building, ensure that people with impaired vision are not left unassisted but are led to a place of safety where a colleague or colleagues should remain with them until the emergency is over.

Suggestions When Assisting Owners of Assistive Animals

  • Do not pet or offer an assistive animal any food without the permission of its owner.
  • When the animal is wearing its harness, it is on duty; if you want the animal not to guide its owner, have the owner remove the animal's harness.
  • Plan for the animal to be evacuated with its owner.
  • In the event you are asked to take the animal while assisting the owner, it is recommended that you (the helper) hold the leash and not the animal's harness.

Hearing Impairments 

When assisting persons with hearing impairments, here are some things to keep in mind:

  • Flick the lights when entering the hearing-impaired person's work area, to get his/her attention.
  • Establish eye contact with the hearing-impaired individual even if an interpreter is present. Face the light; do not cover or turn your face away and never chew gum.
  • Use facial expressions and hand gestures as visual cues.
  • Check to see whether you have been understood and repeat your message if necessary.
  • Use pencil and paper. Write slowly and let the hearing-impaired individual read as you write. Written communication may be especially important if you are unable to understand the individual's speech.
  • Do not allow others to interrupt or joke with you while you are conveying emergency information.
  • Be patient; the hearing-impaired individual may have difficulty comprehending the urgency of your message.
  • Provide the hearing-impaired individual with a flashlight for signaling his/her location in case he/she is separated from the rescuing team or buddy and to facilitate lip-reading in the dark.

Learning Disabilities 

In an emergency, people with learning disabilities may have difficulty recognizing that an emergency exists or being motivated to act by untrained rescuers. They may also have difficulty responding to instructions that require more than a few simple actions. Be aware that:

  • Their visual perception of written instructions or signs may be confused.
  • Their sense of direction may be limited, requiring someone to accompany them.
  • Directions or information may need to be subdivided into simple steps. Be patient.
  • Simple signals and/or symbols should be used (e.g., the graphics used throughout this section).
  • A person's ability to understand speech is often better developed than his/her own vocabulary. Do not talk about a person to others in front of him/her.
  • The people should be treated as adults who happen to have cognitive or learning disabilities. Do not talk down to them or treat them like children.

Attachment III: Effective Use of the Buddy System

This information comes from The Center for Disability Issues and the Health Professions (CDIHP) at Western University of Health Science's guidance on disaster preparedness for people with disabilities.

For an emergency plan for a building to be effective, the person with a disability and his or her buddy must be able to make contact with each other quickly when the need arises. Situations that can prevent their doing so include the following:

  • The buddy is in the building but is absent from the customary work area.
  • The buddy cannot locate the person with a disability because the person is absent from the customary work area.
  • The employee with a disability is working late when the buddy is unavailable.
  • The buddy has left the company and a new one has yet to be identified.
  • The buddy has not been trained in what to do or how to assist.
  • The buddy is inappropriate (e.g., not strong enough).
  • The buddy isn't acceptable to the employee with a disability.
  • The buddy forgets or is frightened and abandons the employee with a disability.

The following suggestions are potential solutions:

  • Assign at least two buddies who are work associates. Alert the floor warden about the work location of the person with a disability.
  • If he/she cannot locate the assigned person, the buddy should alert the floor warden. Employees could be given pagers.
  • Employees with disabilities should identify themselves to the officials in the emergency control center when in the building after hours. The officials coordinate immediate emergency response, call the employee, and alert the proper responding fire service.
  • Employees with disabilities can be given the responsibility for selecting their own buddies; emergency plan reviews, which should be conducted every 2 months, should include checking the status of buddies.
  • The employee with a disability trains the buddy as soon as the buddy is recruited.
  • The employee with a disability is encouraged to select only buddies who are capable. Conducting practice sessions is necessary to ensure that buddies will be able to handle their assigned tasks.
  • Employees with disabilities are encouraged to select only friends/colleagues as buddies.

Attachment IV: U. S. Department of Transportation Emergency Assistance Employee Self-Identification Form

In an emergency, the U.S. Department of Transportation (DOT) is obligated to ensure the safety of its employees and other persons in any facility DOT owns or occupies. Under Sections 501 and 504 of the Rehabilitation Act of 1973, as amended, the Department is further obligated to provide assistance to employees with disabilities or certain other medical conditions (employees with disabilities), during an emergency. Such people are required to identify the need for assistance and to specify exactly what is required.

This document is a voluntary self-identification form through which employees with disabilities may identify their need for assistance during an emergency. The information requested on this form is for the sole purpose of deploying assistance to the undersigned employee with a disability during an emergency. The Rehabilitation Act requires that medical information about applicants and employees be kept confidential except for that provided to first aid, first responders, and safety personnel. Thus, DOT may share information about the type of assistance an individual needs with medical professionals, emergency coordinators, floor captains, colleagues who have volunteered to act as buddies, building security officers who need to confirm that everyone has been evacuated, and other nonmedical personnel who are responsible for ensuring emergency preparedness under the employer's emergency preparedness plan.

1) Name __________________________________________________________________
Last First Middle initial

2) Work Station Location (e.g., Room 2110 Nassif Building) _____________________________

3) Office Phone Number (___) ___________________________________________

4) Cell Phone Number (___) _____________________________________________

5) Home Phone Number (___) ___________________________________________

6) Name of First-line Supervisor __________________________________________

7) First-line Supervisor's Office Phone Number (___) _________________________

8) Name of Buddy _____________________________________________________

9) Buddy's Office Phone Number (___) ____________________________________

10) Your Disability or Condition (e.g., blind/low-vision, deaf, mobility restricted, respiratory condition)


11) Type of Assistance Required During an Emergency (for example, assistance in navigating the building and stairwells during an evacuation, alternative communication systems, evacuation chair)

12) Your Work Schedule (example: First week of the pay period: Monday-Thursday 8:00-5:30, Friday 8:00-4:30. Second week of the pay period: Monday-Thursday 8:00-5:30, Friday RDO)


Employee's Signature __________________________ Date ________________

Privacy Act Statement

The authority under which we solicit this information from you is Sections 501 and 504 of the Rehabilitative Act of 1973 (29 U.S.C. §§ 791 and 794). You are providing this information to us voluntarily. This information may be used by DOT to assist you in the event of an emergency. In addition, information in all DOT Privacy Act systems of records, including this one, may be put to other routine uses (See the Federal Register of April 11, 2000, (65 FR 19475-19570). The effect on your not providing all or any part of the information solicited may result in DOT not having enough information to provide you proper assistance in the event of an emergency.