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: ____________________________________
Home Phone Number: _______________________________ Cell Phone Number: ___________________________________
Address: _______________________________________________________________________________________________
City: ____________________________________________________________ State: _____________ Zip: _______________
IF UNABLE TO REACH ABOVE NOTIFY:
Name: _________________________________________________ Relationship: ____________________________________
Home Phone Number: _______________________________ Cell Phone Number: ___________________________________
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)
day supply is recommended.
Employee’s Signature _______________________________________________ Date: _____________________
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