Visitor Emergency Assistance Request Form printable pdf download

VISITOR EMERGENCY ASSISTANCE REQUEST FORM

Our Agency endeavours to ensure the physical safety of its employees and visitors. We ask visitors with disabilities

requiring instruction or assistance during an emergency situation to use this form to provide us with necessary

information. This information will be provided to members of the Corporate Services Management Team to aid

their response in the event of an emergency situation.

Name:

____________________________________________________________________________

Contact Information:

_____________________________________________________________________

___________________________________________________________________________________________

Emergency Contact:

_______________________________________________________________

____________________________________________________________________________________________

Purpose of attendance at building:

________________________________________________________

____________________________________________________________________________________________

Usual area of building accessed (i.e. family visit area, meeting room, etc.):

____________________________________________________________________________________________

Nature of assistance required (including any equipment, device or personal support):

_____________________________________________________________________________________________

If you are in the building regularly, please indicate when and for what duration:

_____________________________________________________________________________________________

Date information provided:

_________________________________

Valid Until:

_______________________________________________

Signature:

_______________________________________________

Distribution:

Human Resources, Reception

Visitor Emergency Assistance Request Form