Fillable Printable Employee Emergency Contact Form - Tennessee

Employee Emergency Contact Form - Tennessee

Employee Emergency Contact Form

Please return this form to the

Office of Human Resources

Name: _______________________________________________________________________

Home Address: ________________________________________________________________

City: __________________________________ State: ________ Zip: _______________

Home Phone #: _________________________ Cell Phone #: ___________________________

E-Mail Address: _______________________________________________________________

Emergency Contact #1:

Name: ______________________________________________________________________

Home Address: _______________________________________________________________

City: __________________________________ State: ________ Zip: _______________

Work Phone #: _________________________ Cell Phone #: ___________________________

Emergency Contact #2

Name: ______________________________________________________________________

Home Address: _______________________________________________________________

City: __________________________________ State: ________ Zip: _______________

Work Phone #: _________________________ Cell Phone #: ___________________________

Do you give us permission to transport you to the nearest medical facility should you incur serious

illness or injury during normal work hours?

Yes No

If yes, please indicate the name and contact telephone number of the physician or health care

provider that you would like for us to contact:

Name: ______________________________________________________________________

Home Address: _______________________________________________________________

City: __________________________________ State: ________ Zip: _______________

Work Phone #: _________________________ Cell Phone #: ___________________________

In the event of an emergency, please list the names and telephone numbers of

two

individuals you would like us to contact: