CONFIDENTIAL

* Students must stop by the Disability Office in 105 Hewitt to complete the Life Safety Information Card.

Barnard Student Life Safety Information Card

Name/class:                                                                      RA/floor:

Residence hall/Room #:                                                       Phone:

Date completed:                                                                Email:

Do you have a chronic medical condition or physical disability?

Yes _____               No _____                Permanent/Temporary (circle one)

If yes, please check the box below which is most appropriate:

       I cannot go down stairs independently

       I can manage some stairs; the most I can walk is _____ flights

       I must be accompanied on fire stairs

          (check if this pertains to you for any of the following reasons:

tendency to panic, visual impairment, chronic medical condition, other)

       I cannot hear the fire alarm

       I need no assistance

Any additional info:

Procedures for Life Safety and Disability

1. Please complete the ODS Life Safety Information Card (LSIC) if you anticipate any disability-related needs in a life safety crisis.

2. If you are nondisabled but have a need (i.e. unable to hear fire alarm as a heavy sleeper), please complete the LSIC.  Please refer to the Life Safety and Disability Information Sheet (12/07).

3. If your situation changes as a result of a temporary disability, please complete the LSIC at any time during the academic year.

4. Copies of the LSIC will be kept on confidential file in ODS, the Security Office, and your Resident Director's Office to be used in the event of a life safety emergency.

5. Please return the form to your RA or to Disability Services in 105 Hewitt. For further info, contact ODS @ 4/4634 or ods@barnard.edu.

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