Emergency Evacuation Referral Form
for Students with a Disability

To be effective in the event of an emergency evacuation, the University desires to be able to identify and support those students with a disability who need assistance in order to evacuate safely in time of need. If you are a person with a disability, even if you have not otherwise self-identified or asked for an accommodation, the University requests that you complete this form if you feel you need assistance in evacuating during an emergency. Please complete the applicable sections of this form. The requested information will be kept on file by OEP, will not be kept in your student records, and will be used only to develop an emergency plan for you. If you have any questions, please contact: The Office of Emergency Preparedness (OEP) at 706-542-5845, email: prepare@uga.edu.

General Information

Name:	Class Year:
Cell Phone:	Email:
Residence Hall:
Campus Location: Brunswick Griffin Gwinnett Other Georgia Locations Sapelo Skidaway Tifton UGA Campus Zone 1 Zone 2 Zone 3 Zone 4

Functional Limitation (check all that apply) *** Please complete each section that applies to you ***

Mobility:

Auditory:

Visual:

Other:

Mobility
1.	What, if any, mobility devices do you use?        Wheelchair        Scooter        Cane or crutches
	Other:
2.	Do you have a functional limitation with:        Using stairs        Opening doors        Stamina/distance
	Other Limits:
	Other Explain:
3.	Do you use a service animal?        Choose One Yes No
4.	During normal day, if an emergency evacuation were to occur, would you be able to physically evacuate from your work location without assistance?        Choose One Yes No

Auditory
1.	Do you use hearing assistance devices during the day?        Choose One Yes No
	If yes, please describe
2.	During a normal day, if an emergency were to occur would you be able to hear the alarm and evacuate without assistance or special notification?        Choose One Yes No
	If yes, please describe

Visual
1.	Does your visual impairment prohibit or hinder your evacuation during an emergency?        Choose One Yes No
2.	Do you use a cane or guide dog that helps you with travel throughout the day?        Choose One Yes No

Other (e.g. anxiety, psychiatric disorder, asthma, seizure disorder)

What are your concerns about evacuating in an emergency?

I hereby give permission for the UGA Office of Emergency Preparedness and the UGA Disability Resource Center, if needed, to notify University Housing, Building Safety and Security Representative(s), and Emergency Responders in regards to a specific assistance plan to be used during an emergency evacuation.

This form was completed by: