Fillable Emergency Assistance Referral Form (EARF) for Faculty & (Belmont University)

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Emergency Assistance Referral Form (EARF) for Faculty & (Belmont University)

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Emergency Assistance Referral Form (EARF)
for Faculty & Staff with a Disability
To ensure the safety of all faculty and staff during an emergency evacuation, we would like to identify and support
anyone with a disability who may need additional assistance in order to evacuate safely. If you have a disability,
even if you have not otherwise self-identified or asked for an accommodation, and feel you might need assistance
evacuating during an emergency, please complete this form and return it to The Office of Risk Management &
Compliance.
The form will be kept on file by the Office of Risk Management& Compliance only and will not be shared outside
of this office. The information will only be used to develop an emergency plan for you.
If you have any questions, please contact: The Office of Risk Management & Compliance at (615) 460-6766,
email: riskmanagement@belmont.edu
General Information
Name: ________________________________ Work Extension: _______________
Cell Phone: ____________________________ Email: ________________________________
Building: ______________________________ Office Location: ________________________
Functional Limitation (check all that apply)
Mobility ☐ Auditory ☐ Visual ☐ Other ☐
***Please complete each section that applies to you ***
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: ____________________________________________________________________________
Please explain: _____________________________________________________________________
3. Do you use a service animal? Yes ☐ No ☐
Auditory
1. Do you use hearing assistance devices during the day? Yes ☐ No ☐
If yes, please describe ____________________________________________________
2. If an emergency were to occur, would you be able to hear the alarm and evacuate without assistance
or special notification? Yes ☐ No ☐
If no, please describe the type(s) of assistance or notification that would be necessary:
______________________________________________________________________________
September 2017
Emergency Assistance Referral Form (EARF)
for Faculty & Staff with a Disability
Visual
1. Does your visual impairment prohibit or hinder your evacuation during an emergency? Yes ☐ No ☐
2. Do you use a cane or guide dog that helps you with travel throughout the day? 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 Office of Risk Management & Compliance and the Human Resources Office, if
needed, to notify my supervisor, Building Coordinator and Security Representative(s), and Emergency Responders
with regards to a specific assistance plan to be used during an emergency evacuation.
This form was completed by: ___________________________________________________________________
Date: ______________________________________
September 2017
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Emergency Assistance Referral Form (EARF) for Faculty & (Belmont University)

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Completed 17 August 2020

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