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Emergency Notification Form Sample

This emergency notification form collects contact information for an employee in case of an emergency at work. It requests the employee's department, name, cell phone number, primary and secondary emergency contacts with their names, relationships, and phone numbers. It also asks for the employee's family doctor, hospital preference, and any relevant medical history or medications. The form states that copies should be kept within the employee's department and personnel file to ensure the emergency contacts can be accessed if needed.

Uploaded by

Richard R M Thodé
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
138 views

Emergency Notification Form Sample

This emergency notification form collects contact information for an employee in case of an emergency at work. It requests the employee's department, name, cell phone number, primary and secondary emergency contacts with their names, relationships, and phone numbers. It also asks for the employee's family doctor, hospital preference, and any relevant medical history or medications. The form states that copies should be kept within the employee's department and personnel file to ensure the emergency contacts can be accessed if needed.

Uploaded by

Richard R M Thodé
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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EMERGENCY NOTIFICATION FORM

DATE________________________

DEPARTMENT:________________________________________________________________

EMPLOYEE NAME:____________________________________________________________

EMPLOYEE’S CELL PHONE #:_____________________________

IN CASE OF AN EMERGENCY, WHO SHOULD BE CONTACTED:

NAME:______________________________ RELATIONSHIP:____________________

PHONE NUMBER WHERE THEY CAN BE REACHED DURING YOUR WORKING


HOURS:_________________________ alternate or cell phone #___________________

(if above person can not be reached, alternate person to contact):

NAME:______________________________ RELATIONSHIP:____________________

PHONE NUMBER WHERE THEY CAN BE REACHED DURING YOUR WORKING


HOURS:_________________________ alternate or cell phone #___________________

------------------------------------------------------------------------------------------------------------------

FAMILY DOCTOR:_________________________________PHONE:____________________

HOSPITAL PREFERENCE:___________________________

ANY OTHER INFORMATION (OR MEDICAL HISTORY) WHICH WOULD BE HELPFUL


IN CASE OF EMERGENCY (include any medication you take; contact lenses/eyeglasses):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

A COPY OF THIS FORM SHOULD BE KEPT WITHIN THE EMPLOYEE’S DEPARTMENT


AND A COPY KEPT IN EMPLOYEE’S FILE IN PERSONNEL DEPARTMENT.
PLEASE UPDATE THIS INFORMATION WHEN A CHANGE IS NECESSARY.

EMERGENCY NOTIFICATION

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