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Get GSA 3698 2009-2021

Tance in exiting the building in the event of an emergency or evacuation. I acknowledge that I may but am not required to explain why I am requesting such assistance or divulge any medical condition. I understand that information provided in connection with my request will be confidential and used for the purpose of to determining how best to assist me in the event of an emergency/evacuation. Employee's Signature: Date: Approved by: Date: Immediate Supervisor Supervisor's Signature: Date:.

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