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Employee Emergency Contact Form

An employee emergency contact form is a document that lists an employee's family members or friends to be contacted in the event of a workplace accident or injury. It is commonly required during the hiring process and should be updated at least once a year.
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Updated September 24, 2024

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Limiting Liability

If an employer does not properly respond to an injury, they could be liable for not providing a safe workplace. It is recommended for every business to have the emergency contact details of every employee in case there is an employment-related accident.

Main Purpose

When an employee is hurt on the job, supervisors may have an ethical obligation to inform the next of kin or other close relatives or friends. In the worst case, contacting a family member or friend may be a logistical necessity.For employers, it has become standard practice to request emergency contact information from all new hires, whether the job is risky or not. Though the employee may be hesitant to disclose extra personal information, sharing a friend or relative’s phone number and other basic contact details is in the interest of both parties.

There are other cases where an emergency contact can come into play. Consider an employee who abruptly stops showing up to work. The specified contact may be able to vouch for this person’s whereabouts. Similarly, in the case of an employee who is significantly incapacitated by injury or illness, the emergency contact may serve as a go-between should other relatives or friends contact the employer inquiring about the individual.

Selecting an Emergency Contact

Injury and illness are personal and serious matters, so emergency contacts will usually be family or friends with close personal connections to the employee. Expediency matters, too, so employees should think about accessibility when selecting emergency contacts. Will the appointed person be reachable? Is the contact competent to handle high-stress situations?

Sample

EMERGENCY CONTACT FORM FOR [COMPANY NAME]

 

EMPLOYEE DETAILS

Name: [NAME]
Title: [TITLE]
Employee ID: [#]
Department: [DEPT. NAME]
Address: [ADDRESS]
Phone: [PHONE]
E-Mail: [E-MAIL]

EMERGENCY CONTACT

  • Primary Emergency Contact
    • Name: [NAME]
    • Relationship: [RELATIONSHIP]
    • Address: [ADDRESS]
    • Phone: [PHONE]
    • E-Mail: [E-MAIL]
  • 2nd Primary Emergency Contact
    • Name: [NAME]
    • Relationship: [RELATIONSHIP]
    • Address: [ADDRESS]
    • Phone: [PHONE]
    • E-Mail: [E-MAIL]
  • Primary Care Physician
    • Name: [NAME]
    • Phone: [PHONE]
    • Address: [ADDRESS]
  • Medical Information
    • Health Insurance Provider: [PROVIDER]
    • Policy Number: [ADDRESS]
    • Allergies: [ALLERGIES]
    • Medication: [MEDICATION]

CONSENT FOR MEDICAL CARE

In the event that I need emergency services: (check one)

☐ – I GIVE consent to medical treatment by any professional licensed to provide healthcare services.
☐ – I DO NOT consent to any type of medical treatment.

Signature: _________________________________
Date: _________________________________