EMERGENCY CONTACT & EMPLOYEE INFORMATION FORM

Keep current — notify HR of any changes. Store securely; this form contains sensitive personal information.

Employee information

• **Full legal name:** [EMPLOYEE NAME]
• **Preferred name:** ___________________________
• **Employee ID:** [ID] | **Department:** [DEPARTMENT] | **Job title:** [JOB TITLE]
• **Work location:** ___________________________
• **Personal phone:** ___________________________ | **Personal email:** ___________________________
• **Home address:** ___________________________

Emergency contact 1

• **Name:** ___________________________ | **Relationship:** ___________________________
• **Phone (primary):** ___________________________ | **Phone (alt):** ___________________________

Emergency contact 2

• **Name:** ___________________________ | **Relationship:** ___________________________
• **Phone (primary):** ___________________________ | **Phone (alt):** ___________________________

Medical information (optional — used only in an emergency)

• **Allergies:** ___________________________
• **Current medications / conditions responders should know:** ___________________________
• **Physician:** ___________________________ | **Phone:** ___________________________
• **Medical insurance carrier / policy #:** ___________________________

Authorization

I authorize [COMPANY NAME] to contact the persons above in case of emergency. I confirm this information is accurate and will update HR if it changes.

Employee signature: ___________________________  Date: ______________

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For HR use only — Received by: ______________ Date: ______________ Filed: [ ] Yes

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General template only — not legal advice. Have employment counsel review before use, especially for state-specific requirements. Downloaded from AskHrAI (https://askhrai.com/forms/emergency-contact-form).