Employee Emergency Information Record
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1EMPLOYEE EMERGENCY INFORMATION RECORD
Changes indicated below.
No changes to this form.
Name:____________________________________________
EMP Number:_______________________
Preferred Name: ___________________________________
Home Address:_____________________________________
Work Location:______________________
_____________________________________
Phone No. (work):____________________
Phone No. (home):__________________________________
Phone No. (cell):____________________________________
IMMEDIATE SUPERVISOR
EMERGENCY NOTIFICATION(S)
Name________________________________
List information below regarding persons whom you wish
to be notified in the event of injury, illness, or emergency.
Location______________________________
Phone No. ____________________________
___________________________________________
A.
Name
Relationship
________________________________________________
Address
________________________________________________
PHYSICIAN
City
State
Zip
________________________________________________
__________________________________________
Cell Phone No.
Home Phone No.
Work Phone No.
Physician’s Name
__________________________________________
B. ________________________________________________
Name
Relationship
Address
________________________________________________
Address
__________________________________________
City
State
Zip
________________________________________________
City
State
Zip
__________________________________________
________________________________________________
Phone No.
Cell Phone No.
Home Phone No.
Work Phone No.
You are responsible for informing persons at your work site if you have a medical condition that may require immediate first aid. The human
resources and/or safety officer in your agency can help you identify and inform these persons of your first aid requirements. Medical
information is confidential. It is your decision and responsibility to inform others if you believe it necessary for your health and safety while at
work.
__________________________________________________
_____________________________________________
Employee Signature
Date
IMPORTANT – THIS INFORMATION SHOULD BE STORED IN THE EMPLOYEE’S PERSONNEL FILE. SUPERVISOR OR
EMPLOYEES WHO WORK IN THE FIELD SHOULD HAVE IMMEDIATE ACCESS TO THIS INFORMATION.
(TO BE COMPLETED BY EVERY EMPLOYEE AND KEPT CURRENT)
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Parent category: Business