Employee Emergency Contact Form Template

HUMAN RESOURCES / EMPLOYEE RECORDS

Employee Emergency Contact Form

Help us keep you safe. Please complete the information below so we know who to contact and how to assist in an emergency.

Fields marked * are required.

Employee Details

Employee Full Name *

Employee ID *

Job Title *

Department

Mobile Number *

Email Address *

Home Address *

City

Postal / ZIP Code

Primary Emergency Contact

This is the first person we will try to reach.

Contact Full Name *

Relationship *

Mobile Number *

Alternative Phone

Email Address

Preferred Contact Method

Phone Call Text Message Either

Secondary Emergency Contact

An additional person to contact if your primary contact cannot be reached.

Contact Full Name

Relationship

Mobile Number

Alternative Phone

Email Address *

Physician & Emergency Care Preferences

These optional details can help emergency responders or HR coordinate care.

Physician / Doctor's Name

Physician Primary Phone

Physician Secondary Phone

Preferred Emergency Hospital

Medications & Allergies Optional. Share only information you are comfortable providing.

Emergency Response Instructions

Who should be contacted first in a workplace emergency? *

Primary Contact Secondary Contact Both Contacts

Additional Comments or Emergency Instructions

Employee Declaration

I confirm that the details provided are accurate and up to date, and that my emergency contacts have been informed their information may be used in an emergency. *

Employee Signature (Type Full Name) *

Date of Submission *

Your information should be accessible only to authorised HR and emergency response personnel.