Employee Emergency Contact Form

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Employee Emergency Contact Form

An employee emergency contact form is completed by an employee to provide their employer their emergency contacts’ information. The document is kept on file and authorizes the employer to use the information on the form in the event of a workplace accident or emergency. It is recommended that the form be reviewed yearly.

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Last updated June 30th, 2025

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An employee emergency contact form is completed by an employee to provide their employer their emergency contacts’ information. The document is kept on file and authorizes the employer to use the information on the form in the event of a workplace accident or emergency. It is recommended that the form be reviewed yearly.

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EMPLOYEE EMERGENCY CONTACT FORM

Employee Name: [EMPLOYEE NAME] Department: [EMPLOYEE DEPARTMENT]

EMPLOYEE INFORMATION

Address: [EMPLOYEE ADDRESS]
Home Telephone #: [EMPLOYEE HOME PHONE #] Cell #: [EMPLOYEE CELL PHONE #]

EMERGENCY CONTACT INFORMATION

Contact Name: [CONTACT NAME] Relationship: [CONTACT RELATIONSHIP]
Address: [CONTACT ADDRESS] Home Telephone #: [CONTACT HOME PHONE #]
Cell #: [CONTACT CELL PHONE #] Work Telephone #: [CONTACT WORK PHONE #]
Employer: [CONTACT EMPLOYER]

Contact Name: [CONTACT NAME] Relationship: [CONTACT RELATIONSHIP]
Address: [CONTACT ADDRESS] Home Telephone #: [CONTACT HOME PHONE #]
Cell #: [CONTACT CELL PHONE #] Work Telephone #: [CONTACT WORK PHONE #]
Employer: [CONTACT EMPLOYER]

MEDICAL CONTACT INFORMATION

Doctor Name: [DOCTOR NAME] Phone #: [DOCTOR PHONE #]
Dentist Name: [DENTIST NAME] Phone #: [DENTIST PHONE #]

☐ I have voluntarily provided the above contact information and authorize [EMPLOYER NAME] and its representatives to contact any of the above on my behalf in the event of an emergency.

Employee Signature:                                                               Date: ______________
Print Name: [EMPLOYEE NAME]