EMPLOYEE EMERGENCY CONTACT INFORMATION FORM

Form Version: 1.0 | Last Updated: [MONTH] [YEAR]

CONFIDENTIAL INFORMATION

This document contains confidential personal and medical information protected by applicable privacy laws. Access is restricted to authorized personnel only.

I. EMPLOYEE INFORMATION

Full Legal Name: _______________________________ _________________ _______________________________ (First) (Middle) (Last)

Employee ID Number: _______________________________

Department: _______________________________ Position/Title: _______________________________

Work Location:

• Building: _______________________________
• Floor: _______________________________
• Office/Desk Number: _______________________________

Employee Contact Information:

• Cell Phone: _______________________________
• Home Phone: _______________________________
• Personal Email: _______________________________
• Home Address: _______________________________ City: _______________________________ State: _______ ZIP: _____________

II. PRIMARY EMERGENCY CONTACT

Full Legal Name: _______________________________ _________________ _______________________________ (First) (Middle) (Last)

Relationship to Employee: _______________________________

Contact Phone Numbers:

• Cell Phone: _______________________________ ☐ Preferred contact method
• Home Phone: _______________________________ ☐ Preferred contact method
• Work Phone: _______________________________ ☐ Preferred contact method

Email Address: _______________________________

Physical Address: _______________________________ City: _______________________________ State: _______ ZIP: _____________ Country (if outside the U.S.): _______________________________

Languages Spoken: _______________________________

Best Times to Contact: _______________________________

III. SECONDARY EMERGENCY CONTACT

Full Legal Name: _______________________________ _________________ _______________________________ (First) (Middle) (Last)

Relationship to Employee: _______________________________

Contact Phone Numbers:

• Cell Phone: _______________________________ ☐ Preferred contact method
• Home Phone: _______________________________ ☐ Preferred contact method
• Work Phone: _______________________________ ☐ Preferred contact method

Email Address: _______________________________

Physical Address: _______________________________ City: _______________________________ State: _______ ZIP: _____________ Country (if outside the U.S.): _______________________________

Languages Spoken: _______________________________

Best Times to Contact: _______________________________

IV. MEDICAL INFORMATION (OPTIONAL)

Providing this information is voluntary but may assist emergency medical personnel in providing appropriate care.

Medical Conditions: (Please list any conditions that emergency responders should be aware of)

Severe Allergies: (Please list any allergies that could require emergency treatment)

Current Medications: (Please list medications that might be relevant in an emergency)

Blood Type (if known): _______________________________

Primary Physician Information:

• Name: _______________________________
• Phone Number: _______________________________
• Medical Practice/Hospital: _______________________________

Health Insurance Information:

• Provider Name: _______________________________
• Policy Number: _______________________________
• Group Number: _______________________________
• Member Services Phone: _______________________________

V. SPECIAL INSTRUCTIONS

Special Emergency Instructions: (Optional - any specific instructions you want followed in case of emergency)

Religious Preferences: (Optional - any religious considerations relevant in a medical emergency)

Do Not Contact: (Optional - list individuals who should NOT be contacted under any circumstances)

VI. PRIVACY STATEMENT AND CONSENT

Privacy Statement:

The information collected in this Emergency Contact Information Form ("Form") is gathered solely for use in emergency situations involving the employee named herein. [COMPANY NAME] ("Company") recognizes the sensitive nature of this information and is committed to maintaining its confidentiality in accordance with all applicable privacy laws and regulations, including but not limited to the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") where applicable.

This information will be:

1. Stored securely in both electronic and physical formats with appropriate safeguards;
2. Accessible only to authorized personnel with a legitimate need to know in emergency situations;
3. Never used for any purpose other than responding to an emergency involving the employee;
4. Retained only for as long as the individual remains employed with the Company, plus any additional period required by applicable law; and
5. Properly disposed of through secure methods when no longer needed.

Consent for Information Collection and Disclosure:

By completing and signing this Form, I, the undersigned employee, voluntarily provide the information contained herein and expressly consent to:

1. The collection and storage of this information by the Company for emergency purposes;
2. The disclosure of this information to emergency medical personnel, first responders, or other emergency services in the event of a medical or other emergency involving me;
3. The disclosure of this information to the designated emergency contacts listed on this Form in the event of an emergency; and
4. The Company contacting my designated emergency contacts in the event of an emergency.

I understand that:

• Providing medical information in Section IV is completely voluntary;
• I may update or revoke this consent at any time by submitting a new Form;
• It is my responsibility to keep this information current and accurate; and
• The Company will make reasonable efforts to protect the confidentiality of this information but cannot guarantee absolute confidentiality in all circumstances.

HIPAA Compliance Statement:

Any medical information provided in this Form is protected health information under HIPAA. The Company will maintain this information in accordance with HIPAA requirements, including maintaining appropriate administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of this information. This information will only be disclosed as permitted by HIPAA or as authorized by this consent.

VII. FORM ADMINISTRATION

Last Update Date: _______________________________

Annual Review Reminder:

Employees are required to review and update their emergency contact information at least annually or whenever significant changes occur (such as changes in contact information, medical conditions, or emergency contacts). The Company will send periodic reminders to facilitate this process, but ultimate responsibility for maintaining current information rests with the employee.

HR Contact Information:

For questions or assistance regarding this form, please contact:

• HR Department: _______________________________
• Phone: _______________________________
• Email: _______________________________
• Office Location: _______________________________

VIII. EMERGENCY INFORMATION ACCESSIBILITY PLAN

Accessibility of Emergency Contact Information:

This emergency contact information will be:

1. Maintained in the Company's secure Human Resources Information System (HRIS);
2. Available in physical form in a secure location accessible to designated emergency response personnel;
3. Accessible to authorized personnel 24 hours a day, 7 days a week through secure protocols;
4. Available to designated emergency coordinators on each floor/department; and
5. Accessible through secure emergency protocols during after-hours emergencies.

Digital and Physical Storage:

This information will be stored:

1. Digitally in encrypted format within the Company's secure HRIS, protected by appropriate access controls, regular security updates, and backup procedures;
2. Physically in sealed envelopes in a locked, fire-resistant cabinet accessible only to authorized personnel; and
3. In compliance with all applicable data protection and privacy laws.

In the event of power outages or system failures, designated emergency personnel will have access to physical copies through established emergency protocols.

IX. LEGAL COMPLIANCE

ADA Compliance Statement:

This Form and the Company's emergency procedures comply with the Americans with Disabilities Act (ADA). Employees with disabilities may request reasonable accommodations regarding emergency procedures by contacting the HR Department. The Company is committed to ensuring that all employees, regardless of disability status, have equal access to emergency services and support.

State-Specific Requirements:

This Form is designed to comply with all applicable state laws regarding the collection, storage, and use of emergency contact information. The Company acknowledges that state requirements may vary and commits to maintaining compliance with the specific requirements of each state in which it operates. Employees may request information about state-specific requirements by contacting the HR Department.

X. EMPLOYEE ACKNOWLEDGMENT

I, the undersigned employee, acknowledge that:

1. I have voluntarily provided the information contained in this Form;
2. I have read and understand the privacy statement and consent provisions;
3. I understand it is my responsibility to keep this information current and accurate;
4. I will notify the HR Department promptly of any changes to this information; and
5. I consent to the use of this information as described in this Form.

Employee Signature: _______________________________ Date: _________________

Print Name: _______________________________

FOR HR USE ONLY

Received by: _______________________________ Date: _________________

Entered into HRIS by: _______________________________ Date: _________________

Next scheduled review date: _________________