Emergency Contact Information Form of Employee
Emergency Contact Information Form of Employee
Emergency Contact Information Form
Employee Information
Employee Name: ________________________________________________________
Employee ID: ________________________________________________________
Department: ________________________________________________________
Job Title: ________________________________________________________
Work Phone: ________________________________________________________
Personal Mobile Phone: ________________________________________________________
Personal Email: ________________________________________________________
Home Address: ________________________________________________________
Emergency Contact #1
Full Name: ________________________________________________________
Relationship to Employee: ________________________________________________________
Home Phone: ________________________________________________________
Mobile Phone: ________________________________________________________
Work Phone: ________________________________________________________
Email Address: ________________________________________________________
Emergency Contact #2
Full Name: ________________________________________________________
Relationship to Employee: ________________________________________________________
Home Phone: ________________________________________________________
Mobile Phone: ________________________________________________________
Work Phone: ________________________________________________________
Email Address: ________________________________________________________
Medical Information (Optional but highly recommended)
Allergies: ________________________________________________________
Medical Conditions: ________________________________________________________
Medications: ________________________________________________________
Blood Type: ________________________________________________________
Primary Physician: ________________________________________________________
Insurance Provider: ________________________________________________________
Policy Number: ________________________________________________________
Employee Signature: _________________________________________ Date: ______________
Please Note:
Keep this information up-to-date. Notify your employer of any changes to your emergency contact information.
Provide complete and accurate information to ensure we can reach your designated contacts in case of an emergency.
This form will be kept confidential and used only for emergency purposes.
Emergency Contact Information Form of Employee :
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