Persons Requiring Assistance

PERSONS REQUIRING EVACUATION AIDE

PERSONS REQUIRING ASSISTANCE EMERGENCY PLANNING FORM

Purpose: This form is used to identify and document emergency response and evacuation assistance requirements. Complete one form per individual. Medical diagnoses and medical history are not required.

INDIVIDUAL AND LOCATION

TYPE OF ASSISTANCE REQUIRED

Select all that apply
Assistance Type(Required)

DURATION OF ASSISTANCE REQUIREMENT

Duration
MM slash DD slash YYYY
MM slash DD slash YYYY

SPECIFIC ASSISTANCE AND EVACUATION INSTRUCTIONS

Document the specific assistance required during an emergency, including: Communication methods, mobility devices, evacuation considerations, refuge locations, and any other information necessary for safe emergency response.

DESIGNATED EMERGENCY ASSISTANT (BUDDY)

(if applicable)
Arrangements Confirmed With Individual and Buddy

COMPLETION AND REVIEW

This form must be reviewed annually and whenever assistance requirements, work location, or buddy arrangements change.
MM slash DD slash YYYY
MM slash DD slash YYYY

CONFIDENTIAL WHEN COMPLETED

This document contains personal information collected solely for emergency preparedness, response, and evacuation planning purposes. Access must be restricted to authorized personnel with a legitimate operational need to know.

Note that Person Requiring Assistance cannot serve as other’s assistants.