HumanResources_EmergencyInformation

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					                       EMERGENCY INFORMATION
                                  [Company Name]


EMPLOYEE NAME                 EMPLOYEE NUMBER                    SOCIAL SECURITY NUMBER



POSITION                      DEPARTMENT                         MANAGER



WORK PHONE                    HIRE DATE                          TODAY’S DATE




EMPLOYEE’S HOME INFORMATION
HOME PHONE                    CELL PHONE                         PAGER



STREET                                          CITY, STATE AND ZIP




EMERGENCY CONTACT—1
NAME                                            HOME PHONE       WORK PHONE     CELL PHONE



STREET                                          CITY, STATE AND ZIP



RELATIONSHIP TO EMPLOYEE




EMERGENCY CONTACT—2
NAME                                            HOME PHONE       WORK PHONE     CELL PHONE



STREET                                          CITY, STATE AND ZIP



RELATIONSHIP TO EMPLOYEE




                                 Emergency Information, Page 1
PHYSICIAN INFORMATION—1
NAME                                             PHONE NUMBER



STREET                                           CITY, STATE AND ZIP




       [ ] GP        [ ] OB/GYN            [ ] Dentist            [ ] Eye Doctor   [ ] Allergist




PHYSICIAN INFORMATION—2
NAME                                             PHONE NUMBER



STREET                                           CITY, STATE AND ZIP




       [ ] GP        [ ] OB/GYN            [ ] Dentist            [ ] Eye Doctor   [ ] Allergist




PHYSICIAN INFORMATION—3
NAME                                             PHONE NUMBER



STREET                                           CITY, STATE AND ZIP



       [ ] GP        [ ] OB/GYN            [ ] Dentist            [ ] Eye Doctor   [ ] Allergist




                                  Emergency Information, Page 2

				
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