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Workplace Violence Handbook
Appendix 3 - Emergency Contact Information Sheet

Use of this information sheet is voluntary. The completed form can be given to your supervisor, who will retain it in his/her files and use the information only in the event of an emergency requiring notification of a relative or significant other. If you elect to provide this information to your supervisor, whether using this sheet or in another fashion, you should update it whenever there are changes.

Employee Name:

_____________________________

Home Address:

_____________________________
_____________________________
_____________________________

Home Phone Number:

_____________________________

Emergency Contact Person:
(Name and Phone Numbers)

_____________________________
_____________________________
_____________________________

Alternate Contact:
(Name and Phone Numbers)

_____________________________
_____________________________
_____________________________

Physician Name:

_____________________________
Physician Phone Number:
_____________________________

Blood Type:

_____________________________

Allergies:

_____________________________
_____________________________

NOTE TO SUPERVISORS: The information on this sheet is confidential and should be stored in a secure location; access to the information should be limited to those with a need to know during an emergency.






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Page Last Modified: Monday, 28-Apr-2014 10:47:57 EDT