Fillable Special Needs Self Identification Form (Idaho State University)

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Special Needs Self Identification Form (Idaho State University)

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The Special Needs Self Identification Form (Idaho State University) form is 5 pages long and contains:

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File type: PDF

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ISU Disabled/Special Needs Persons
Self-Identification Form
Purpose Statement
The purpose of this form is for disabled or special needs faculty, staff and students to self-
identify before an emergency so the best effort to locate, notify, evacuate or shelter them can
be performed. Please fill-out the information truthfully. ISU understands that disabled and
special needs persons may not be where their schedule states, multiple forms of contact and
having a buddy system will help aid each special needs or disabled person in the event of
emergency.
Name:
Disability:
Associated Limitations with your disability?
Phone #:
Email:
Full Address:
Alternate Contacts
Name: Name:
Relation: Relation:
Phone #: Phone #:
IMPORTANT: At the end of this form attach your class/work schedule, and/or fill
out the weekly schedule in this form!
Alternate Contacts
Name: Name:
Relation: Relation:
Phone #: Phone #:
Questionnaire
Are you familiar with the ISU emergency evacuation/sheltering plan?
Yes No
Do you keep your cell phone with you at all times?
Yes No
Are you comfortable asking for help if an emergency happens?
Yes No
Do you understand that physical contact may be necessary to help you evacuate?
Yes No
Can you evacuate quickly if necessary, on your own?
Yes No
Can you hear the fire alarm?
Yes No
Could you activate the fire alarm if you discover a fire?
Yes No
Have you asked a roommate, classmate, coworker to be your “buddy” to aid you? (See buddy
system in the emergency evacuation/sheltering plan)
Yes No
Will you be able to contact someone to inform them of your current location if you are not
where your schedule states?
Yes No
On the calendar below students, faculty and staff can put information such as but not limited
to; work schedule, where and when you attend church (ext.). Try to be brief with your wording
and designate the places where you know you will most likely be and provide a time period. In
addition, there is a notes section where you can provide more specific details about your
schedule (most importantly specific locations).
Example
Sun
Mon
Tue
Wed
Thu
Sat
Church
1:30pm-
3:30pm
Work
8:00am-
12:00pm
Work
8:00am-
12:00pm
Work
8:00am-
12:00pm
Month(s):
Sun
Mon
Tue
Thu
Fri
Sat
Notes about calendar
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________
Please attach other Class/Work Schedules after this page.
Terms of Use
I, (name of applicant)_________________________ hereby agree that the information I
provided in the Self-Identification form is voluntary and that the information is accurate. I
further understand that the information I provide is subject to change and it is my responsibility
to keep the information accurate and up-to-date. I understand the information I provide is for
Idaho State University and other local emergency response agencies to notify, warn, evacuate,
locate and respond in all various disaster situations. I understand that the best possible
response will be provided to me, and that Idaho State University and other local emergency
response agencies are not liable for the failure of the Self-Identification process in providing
response prior to, during, or after a disaster. I agree to cooperate with Idaho State University
and any emergency response personnel in a disaster situation.
Signature: __________________________________Date:_______________________
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Special Needs Self Identification Form (Idaho State University)

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Completed 27 July 2020

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