Employee Emergency Information Form printable pdf download

Employee Emergency Information Form

In an effort to ensure the Company has accurate and current information, the following form must be

completed and signed. The information requested on this form is personal and is therefore considered

confidential. It will be used only for valid business purposes, such as compensation, benefits, and

certain government reports required by law. If you have questions about the requested information,

please see your Human Resources Manager.

Employee Name: _________________________________________

Date: ____________________

Employee Phone Numbers: (Home) ________________________ (Cell) _________________________

Employee Email Address: _______________________________________________________________

EMERGENCY CONTACT INFORMATION

1. Contact Name: _______________________________________ Relationship: ___________________

Phone Numbers: (Home) _________________________ (Work/Cell) _________________________

2. Contact Name: _______________________________________ Relationship: ___________________

Phone Numbers: (Home) _________________________ (Work/Cell) _________________________

HIPPA privacy act code – employee’s mother’s maiden name: ___________________________

Please contact Human Resources if any of the above information changes.

Employee Emergency Information Form