Date created: January 6, 2020

Revision Date: December 18th, 2023

Individualized Employee Emergency Response Policy & Information Form

Under the Employment Standard of the Accessibility for Ontarians with Disability Act, 2005 (AODA), employers must, among other things, create an “Individualized Workplace Emergency Response Plan (IWERP)” for any worker with a disability who needs assistance during a workplace emergency, such as fire, power outage, or severe weather conditions.

An Individualized Workplace Emergency Response Plan is a written document created by the employer with input from the worker, that details all assistance a worker needs during a workplace emergency. Individualized Workplace Emergency Response Plan helps workers in cases where the employer cannot implement some of the required emergency strategies, or where the worker needs other forms of assistance.

Topnotch Employment Services Inc. is committed to complying with all its obligations under the Accessibility for Ontarians with Disability Act, 2005 (AODA).

In furtherance of our obligations in the event of an emergency, we require the full cooperation of every worker who has a disability. Therefore, if you have a disability that requires you to have assistance during an emergency, please complete Section “A” of the attached “Individualized Employee Emergency Response Form” and return the Form to your Manager. By providing the required information in Section “A” of the Form, your Manager will be able to properly determine your individualized needs and record those needs in Section “B” of the Form. In addition, your Manager shall meet with you to obtain any clarification or further details regarding what assistance you may need and actions to be taken in an emergency. Please be assured that all information provided shall be kept in strict confidentiality. Only with your consent, your Manager shall share your Individualized Emergency Response Plan with people designated to assist you should an emergency arise.

An Individualized Workplace Emergency Response Plan may be subject to review as new information becomes available, such as any change in the worker’s disability.

Should you have any questions or concerns, please do not hesitate to contact the Office of Topnotch Employment Services Inc. @ 416-741-0066/2770 or e-mail: [email protected] 

2365 Finch Avenue WP5t Suite 207, Toronto, Ontario M9M 2W8 • Telephone: (416) 741 -2770 • Fax: (416) 741-0069

Individualized Employee Emergency Response Information Form For AODA

This Form should be completed by any employee who requires assistance during a workplace emergency because of a disability along with the employee’s manager. This Form shall be added to the employee’s Individual Accommodation Plan, if applicable.

To the employee: Please complete Section “A” if you have a disability which requires that you be provided with assistance in the case of an emergency. Please return the completed Form to your manager who will arrange a meeting with you. A|I information in this document is confidential between you and your manager and will be shared by your manager only with your consent, as may be required.

Note to the manager: Please review Section “A” of the Form and complete Section “B” in consultation with the employee. Do not share the contents of this Form without the employee’s consent and only as necessary.

SECTION “A”: TO BE COMPLETED BY THE EMPLOYEE:

EMPLOYEE INFORMATION

Name:

Address: Position:

Telephone: E-mail: EMERGENCY CONTACT INFORMATION

Name:

Mobile phone:

Relationship:

Telephone: Mobile phone:

E-mail:

WORK LOCATION

Address: Work Number:

NATURE OF DISABILITY

Please provide the nature of your disability without providing diagnosis (i.e., visual impairment):

EMERGENCY ALERTS

You wish to be informed of an emergency situation by: Existing alarm system.

2365 Finch Avenue West Suite 207, Toronto, Ontario M9M 2W8 • Telephone: (416) 741 -2770 • Fax: (416) 741-0069 

E-mail: [email protected] • website: www.topnotchempIoyment.com

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Pager device

Visual alarm system

Co-worker

Other (specify):

(continued …)

SECTION “B”: TO BE COMPLETED BY MANAGER IN CONJUNCTION WITH EMPLOYEE

ASSISTANCE METHODS

List types of assistance (e.g., staff assistance or transfer instructions) the employee requires because of a disability.

EQUIPMENT REQUIRED

List any devices required, where the device(s) are stored and how to use them.

DESCRIBE EVACUATION ROUTE AND PROCEDURE

DESCRIBE ANY ALTERNATIVE EVACUATION ROUTE

EMERGENCY SUPPORT STAFF

The following people have been designated to help, , in an emergency:

CONSENT TO SHARE EMERGENCY RESPONSE INFORMATION

I, , give consent for Topnotch Employment Services Inc to share this Individualized Workplace Emergency Response Information with the individuals listed above, who have been designated to help me in an emergency.

Employee’s name Manager’s Name Manager’Signature

Employee’s signature

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