Employee Self Identification Form - Request For Assistance During An Emergency - Department Of Energy
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Department of Energy
Request for Assistance During an Emergency
Employee Self Identification
This form is to be used by persons who expect that they will need assistance during an emergency. The purpose of
this form is to help Program Office supervisors and the Incident Management Team ensure that plans are in place to
assist persons with temporary or permanent disabilities during an emergency. The Incident Management Team
would rather work with someone on a specific plan of action before an emergency than have an individual
experience a problem in the middle of an emergency.
Note: There are many conditions which might require assistance during an emergency. Conditions can be temporary
(e.g., a broken leg, on chemotherapy drugs, or pregnancy) or permanent (e.g., a hearing loss, an amputated limb,
asthma).
Completion of this form is voluntary. Any information provided will be kept confidential and shared with those
having a need to know (e.g., the assigned assistant, the Program Office Safety and Health Representative, the Health
Clinic, and the Incident Management Team). The information may be aggregated into lists, charts, and/or graphs.
Information provided need only describe the kind of assistance required during an emergency. Disclosure of any
medical condition is not necessary. Employees should provide only information that will be essential to those
assisting them.
Upon completion of the form, please return it to your immediate supervisor. Supervisors shall forward the original
to the Office of Headquarters Safety, Health and MA Security in Room GE-112. Call 202-586-1005 for additional
information and guidance.
I request special assistance during emergencies:
Name:_______________________________
Organization (including code):_________________________
Phone Number:________________________
Duty Hours:________________________________________
Building:_____________________________
Office Location:_____________________________________
Supervisor:___________________________
Supervisor’s Phone Number:________________________
Floor Warden:_________________________
Assistant:_______________________________________
The following is a description of the type of assistance I will require:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Note: The description field is electronically fillable, but may not follow the line separation on the page. It may still be filled in electronically.
My condition is:
[ ] permanent
[ ] temporary
If temporary, I will not need assistance after (date):_____________________________________
Thank you,
Signature:________________________________
Date:_______________
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