Form Gsa 3698 - Employee Requesting Evacuation Assistance 2009
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1Employee Requesting Evacuation Assistance
Employee Name:
E-mail Address:
Date Requested:
Division:
Telephone Number:
Department:
Room Number:
I am hereby requesting that GSA provide me with assistance in exiting the building in the
event of an emergency or evacuation. I acknowledge that I may but am not required to
explain why I am requesting such assistance or divulge any medical condition. I
understand that information provided in connection with my request will be confidential
and used for the purpose of to determining how best to assist me in the event of an
emergency/evacuation.
Employee Signature:
Date:
Approved by:
Date:
Immediate Supervisor
Supervisor's Signature:
Date:
This form should be forwarded to the Security Division.
Security Division Use Only
Date Received:
Received by:
Special Notes:
GENERAL SERVICES ADMINISTRATION
GSA 3698 (10/2009)
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Parent category: Financial