Find out the sample and contents of an employee emergency information form.

In a workplace setting, sometimes emergencies are inevitable. Therefore, it is important to take a pro-active approach to managing risks. One way to do this is to fill the employee emergency information. It collects all the information, which might be required by paramedics and other parties if an employee is involved in an emergency. What should your employee emergency information record form include?


Components of the form

In most cases, the form comprises of three key sections such as:

Personal information

In this section, you should include all the information about the employee. They are the employee ID, full name, gender, home address, place of birth, county or district, passport number, driving license, national tax number, and their email address. All this information is beneficial when identifying the employee.

Medical information

It is crucial to document employee’s health history. This is because when the individual is involved in an emergency incident, the physicians will rely on their medical records to provide appropriate treatment. Some of the crucial details you should fill in this section include the doctor’s name and address, contacts, the blood group of the employee, allergies, medical conditions, and any medications that the individual is taking currently.

Emergency information

This is the last section in the form. It entails the emergency contact name, their relationship with the employee, together with their contact and address. Completing this form is believed to be beneficial since it helps in building employee’s emergency response information. Based on the law, there are no limitations on the number of items to add in this form. However, as the employer, you should gather all the information, which will be valuable in case of an emergency.

Employee emergency information form sample

Employee Emergency Information Form

Personal Information

Name: […] Date: […]

Home Address: […]

Home Contact: […]

Cell Phone No: […]

Medical Information

Health Insurance Provider: […] Tel. No: […]

Doctor’s Name: […] Tel. No: […]

Physician’s Name: […]

Hospital: […]

Know allergies and medications: […]

Other information that the medical professional should know […]

Emergency Contact Information

Name: […] Relationship: […]

Employer: […] Work Tel. No: […]

Cell Phone Number: […] Home Tel. No: […]

Name: […] Relationship: […]

Employer: […] Work Tel. No: […]

Cell Phone Number: […] Home Tel. No: […]

Please submit the form to the supervisor

Note: If you care about your privacy, submit the employee emergency information form in an envelope. Be sure to include your name on it and indicate “Only to Be Opened in the Event of Medical Emergency.”

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