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Evacuation Assistance Request
People with mobility impairment may need additional assistance during an emergency evacuation. Impairments can take many forms and may be temporary (i.e. strained ankle), short term (i.e. seasonal bronchitis), or long term (i.e. quadriplegic). Special attention may also need to be given to young children.

This form is for individuals that wish to self-identify his or her need for assistance during an emergency evacuation. By providing this information and discussing it with the Fire Safety Director, the best evacuation option(s) for you can be determined and planned for.

Participation and information is a voluntary act of disclosure on the part of the individual. The information you provide to us is confidential and will only be given to those designated by the Emergency Evacuation Plan and to emergency personnel.

If you or someone in your household would need additional assistance during an emergency evacuation, please complete this form.

You may also view the City of Chicago High Rise Evacuation Plan as well as other tips HERE.

Resident Name:*
Property Address:*
Unit Number:*
Email Address:
Home Phone:*
Cell Phone:
Impairment Type:*
Description of anticipated assistance requested:*
Describe any equipment or special procedures necessary to meet your safety needs:
To prevent automated SPAM, please enter LALX to submit your form (case sensitive):*
 

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1045 W. Lawrence Ave. | Chicago | IL, 60640 | 312-466-8100