HTML Preview University Employee Emergency Notification Form page number 1.

EMPLOYEE EMERGENCY INFORMATION

Employee Name: ________________________________________ Red ID #: _______________________________________

Address: _______________________________________________________________________________________________

City: _________________________________________________________ State: _____________ Zip: __________________

Home Phone Number: _____________________________ E-mail Address: _________________________________________

Cell Phone Number: _______________________________ Work Phone Number: ____________________________________

Date of Birth: _________________________________Date of Hire: _______________________________________________

IN CASE OF EMERGENCY NOTIFY:

Name: _________________________________________________ Relationship: ____________________________________

Address: _______________________________________________________________________________________________

City: ____________________________________________________________ State: _____________ Zip: _______________

Date form completed/updated: (To be verified or updated bi-annually) ____________________________________

Unusual Medical Conditions:

____________________________________________________________________________________________

Please List Medicine/Substance Allergies:

____________________________________________________________________________________________

NOTICE TO EMPLOYEES: In the event of an emergency or disaster, transportation

and availability to medical service may be delayed. It is recommended that any

required health sustaining medication be in your possession. A minimum three (3)