EMPLOYEE EMERGENCY CONTACT FORM
EMPLOYEE'S NAME:
__________________________________________
DATE:
__________________________________________
The information in this form is to be used strictly in an emergency situation. This would
include: medical attention, police and fire department concerns, and/or your safety.
Please list family members or friends that you would like us to notify in case of an
emergency while on the job. Return to the Human Resources Manager promptly when
complete. This form will be kept in your employee file in the Department of Medicine -
Vancouver Hospital.
CONTACT:
1. Name:
___________________________________________________
Relationship:
___________________________________________________
Address:
___________________________________________________
Phone: (Home) _____________________ (Business)_____________________
2. Name:
___________________________________________________
Relationship:
___________________________________________________
Address:
___________________________________________________
Phone: (Home) _____________________ (Business)_____________________
3. Name:
___________________________________________________
Relationship:
___________________________________________________
Address:
___________________________________________________
Phone: (Home) _____________________ (Business)_____________________
Attention:
Human Resources Manager, Department of Medicine
10th Floor, Gordon & Leslie Diamond Health Care Centre
2775 Laurel St, Vancouver, B.C., V5Z lM9 (Fax - 604-875-4886)