Emergency Contact Form

EMERGENCY CONTACT FORM This form collects information so [Company Name] can reach your designated contacts in an emergency. Please keep this information current. EMPLOYEE INFORMATION Full Name: [First Name] [Last Name] Employee ID: [Number] | Job Title: [Title] | Department: [Department] Work Location: [Location] | Work Phone: [Phone] | Work Email: [Email] Personal Phone: [Phone] SECTION A: PRIMARY EMERGENCY CONTACT (Contacted first) Full Name: [First Name] [Last Name] Relationship: [Spouse / Partner / Parent / Sibling / Child / Friend / Other] Home Phone: [Number] | Mobile Phone: [Number] | Work Phone: [Number] Email: [Email] Address: [Street, City, State, Postal Code] Authorised to make medical decisions if incapacitated?: ☐ Yes ☐ No SECTION B: SECONDARY EMERGENCY CONTACT (Contacted if primary unreachable) Full Name: [First Name] [Last Name] Relationship: [Spouse / Partner / Parent / Sibling / Child / Friend / Other] Home Phone: [Number] | Mobile Phone: [Number] | Work Phone: [Number] Email: [Email] Address: [Street, City, State, Postal Code] SECTION C: ADDITIONAL CONTACTS (Optional) Contact 3: [Name] | [Relation] | [Phone] Contact 4: [Name] | [Relation] | [Phone] SECTION D: MEDICAL INFORMATION (Optional — emergency use only) Blood Group: [Type] Allergies (medications, food, environmental): [List] Current Medications: [List medications and dosages] Chronic Conditions: [List conditions] Primary Care Physician: [Name] | Phone: [Phone] Health Insurance Provider: [Provider] | Policy #: [Number] Emergency Room Preference: [Hospital/Facility] SECTION E: AUTHORIZATION I confirm this information is accurate. I will update this form when details change. I authorise [Company Name] to contact listed individuals in an emergency involving me. Signature: _______________________ Date: _______________________ FOR HR USE ONLY Received: [Date] | Entered in HRIS: ☐ Yes — by [Name] on [Date] Annual review reminder set: ☐ Yes