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.
