Fillable Employee Emergency Information Form printable pdf download

Employee Emergency Information Form

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Complete Employee Emergency Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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EMPLOYEE EMERGENCY INFORMATION

Employee Name: ________________________________________ Red ID #: _______________________________________

Address: _______________________________________________________________________________________________

City: _________________________________________________________ State: _____________ Zip: __________________

Home Phone Number: _____________________________ E-mail Address: _________________________________________

Cell Phone Number: _______________________________ Work Phone Number: ____________________________________

Date of Birth: _________________________________Date of Hire: _______________________________________________

IN CASE OF EMERGENCY NOTIFY:

Name: _________________________________________________ Relationship: ____________________________________

Home Phone Number: _______________________________ Cell Phone Number: ___________________________________

Address: _______________________________________________________________________________________________

City: ____________________________________________________________ State: _____________ Zip: _______________

IF UNABLE TO REACH ABOVE NOTIFY:

Name: _________________________________________________ Relationship: ____________________________________

Home Phone Number: _______________________________ Cell Phone Number: ___________________________________

Address: _______________________________________________________________________________________________

City: ____________________________________________________________ State: _____________ Zip: _______________

Date form completed/updated: (To be verified or updated bi-annually) ____________________________________

Unusual Medical Conditions:

____________________________________________________________________________________________

Please List Medicine/Substance Allergies:

____________________________________________________________________________________________

NOTICE TO EMPLOYEES: In the event of an emergency or disaster, transportation

and availability to medical service may be delayed. It is recommended that any

required health sustaining medication be in your possession. A minimum three (3)

day supply is recommended.

Employee’s Signature _______________________________________________ Date: _____________________

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Employee Emergency Information Form

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