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Individualized Emergency Response Plan Consent Form

The Accessibility for Ontarians with Disabilities Act (AODA) states that every employer shall provide individualized workplace emergency response information to employees who have identified to the employer that they have a disability that requires accommodation.

In order to fulfill our duty to accommodate, we must be made aware of any needed accommodations so that we can respond with an appropriate individualized emergency plan.

All individualized workplace emergency response documentation is available in an accessible format on request through Return to Work and Accommodation Services

  • hrrtw@queensu.ca
  • Human Resources, Fleming Hall, Stewart-Pollock Wing, First Floor
Employee Information

I may need some assistance in evacuating the building or coping with a workplace emergency.

Notice of Collection

The personal information on this form is collected under the authority of the Royal Charter of 1841, as amended. The personal information on this form will be used to implement an individual emergency response plan and will be shared your supervisor and the Human Resources Return to Work and Accommodation Service unit. Further disclosure of the information will only occur with your consent. If you have any questions or concerns about the information collected or how it will be used please contact the Department of Environmental Health & Safety, Rideau Building, Room 326 or by telephone at 613‐533‐2999.


This form submission will be directed to: Return to Work and Accommodation Services, Human Resources.

You will also receive a copy of the submission by email.