Number of Pages: 1

Who to use it with? 

• Employees

What is it?

• To be filled out by employees who voluntarily shares contact information for employer to contact during an emergency (e.g., medical) 

Why should you use it?

• In the event of an emergency, employer will be able to reach out to the emergency contact of the employee

• In the case an employee has shared a medical condition, employer should use this form to obtain authorization to share medical condition with the designated emergency contact during medical emergency 

Disclaimer/Recommendations:

• This form asks for employee's voluntary disclosure of medical condition. Employer should follow state and local privacy regulations on how to properly store this document.