EMPLOYEE EMERGENCY CONTACT FORM

EMPLOYEE INFORMATION
EMPLOYEE NAME	EMPLOYEE ID
SSN	POSITION
ADDRESS	PHONE 1
PHONE 2
EMAIL
DATE COMPLETED
EMERGENCY CONTACTS
CONTACT 1 NAME	RELATIONSHIP
PHONE 1	PHONE 2
ADDRESS
CONTACT 2 NAME	RELATIONSHIP
PHONE 1	PHONE 2
ADDRESS
COMMENTS Please provide details for any medical or personal info you would wish to be shared with an Emergency Care Provider.
ALLERGIES
ALLERGIES TO MEDICATIONS
MEDICATIONS CURRENTLY TAKEN
OTHER
MEDICAL CONTACT INFO
DOCTOR NAME	PHONE
DENTIST NAME	PHONE
PREFERRED HOSPITAL	PHONE

The above information has been provided voluntarily, and I authorize contact on my behalf in the event of an emergency.

EMPLOYEE SIGNATURE	DATE
SUBMIT COMPLETED FORM TO	REC’D BY	DATE REC’D

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