Campus Safety & Security Department

Student & Staff Emergency Self-Identification Form

The John Marshall Law School is committed to ensuring the safety of students, employees, and other visitors to all buildings. That commitment includes providing assistance to employees with disabilities or certain medical conditions during an emergency. Such persons are requested to identify their need for assistance and to specify what is required for a safe evacuation of the building during an emergency.

This document is a voluntary self-identification form through which students, employees, and visitors with disabilities may identify their need for assistance during an emergency. The information requested on this form is for the sole purpose of deploying assistance to the undersigned person during an emergency. The Rehabilitation Act of 1973, as amended, requires that medical information about applicants be kept confidential except for that provided to first aid, first responders, and safety and health personnel. Thus, the Director of Safety & Security, Fire Safety Director, Life Safety Coordinator for Campus Safety, and the Security Department may share information about the type of assistance and individual needs with medical professionals, emergency coordinators, emergency evacuation personnel and security officials who need to confirm that everyone has been evacuated, and other non-medical personnel who are responsible for ensuring emergency preparedness.

 Request form

A red asterisk (*) indicates a required field.

  

If this is a temporary request, please provide a date when assistance will no longer be needed.

Work/Study Station location:


*Your work schedule (e.g. Monday-Friday, 8 a.m.-4 p.m.):

Your disability or medical condition (check all that apply):







Please provide details of your heart condition:

Other (please provide additional details):

Type of assistance required during an emergency evacuation:



Please describe the emergency assistance you may require:

By checking this box, you acknowledge that all of the information on this form is true. A checked box indicates your acceptance and signature.

Student and Staff: This form will be submitted to the Campus Safety & Security Department via email. You may visit them in person at 304 S. State Street Lobby.

A confirmation of this form will be sent to the email address provided above. If you have any questions, please call the Director of Campus Safety & Security at 312.386.2823 or the Security Life Safety Coordinator at 312.427.2737 ext 501.

Contact Us

Safety & Security Stations

State St. Entrance
304 S. State St.
Phone: 312.427.2737 ext. 501

Plymouth Ct. Entrance
315 S. Plymouth Ct.
Phone: 312.427.2737 ext. 507

Veterans Entrance
19 W. Jackson Blvd.
Phone: 312.427.2737 ext. 503