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Employee Emergency Contact Form

Employee Information

Full Name		Employee ID
Department		Job Title
Mobile Phone		Home Phone
Home Address
Personal Email

Primary Emergency Contact

Full Name		Relationship
Mobile Phone		Home / Work Phone
Email
Address

Secondary Emergency Contact

Full Name		Relationship
Mobile Phone		Home / Work Phone
Email
Address

Medical Information (optional)

Physician Name		Physician Phone
Preferred Hospital
Allergies / Conditions Responders Should Know

I authorize the company to contact the people listed above in an emergency. I will update this form if my information changes.

Employee Signature

Date

※ Medical information is voluntary and will be kept confidential and stored separately from the personnel file. Review and update this form once a year.

How to fill out an Employee Emergency Contact Form

Employee Emergency Contact Form template preview — Free Employee Emergency Contact Form template

An employee emergency contact form gives the employer the names and phone numbers of the people to call if an employee is hurt or becomes ill at work. It also has an optional section for medical details the employee wants responders to know.

How to fill it out

Enter the employee’s name, ID, department, phones, address and email.
Add a primary emergency contact with relationship, phones, email and address.
Add a secondary contact in case the first cannot be reached.
Optionally add physician, preferred hospital and allergies or conditions.
Sign and date the form and return it to HR.

Tips

Medical information should be voluntary and kept confidential.
Ask employees to review the form once a year or when they move.
Store forms where managers can reach them quickly in an emergency.
List contacts who are likely to answer during work hours.