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 with the information of individuals who may be contacted in the event they experience a workplace accident or emergency. The document is entered into the employer’s records and authorizes them to use the information on the form if needed. It is recommended that the form be reviewed yearly.

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Last updated June 15th, 2025

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An employee emergency contact form is completed by an employee to provide their employer with the information of individuals who may be contacted in the event they experience a workplace accident or emergency. The document is entered into the employer’s records and authorizes them to use the information on the form if needed. It is recommended that the form be reviewed yearly.

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Sample

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]