Emergency Information

The Staff Emergency Information form is vital in the event of an emergency.  Per HIPPA guidelines, this information will remain confidential and secure.  If there is information you are not comfortable completing, please visit the Health Suite to speak with one of our nurses.

Staff Emergency Information

Name (Last, First): 

Date of Birth (mm/dd/yyyy): 

Room/Office Number: 

Program/Department: 

Cell Phone Number: 

Personal Email: 

Emergency Contact Person #1

Name: 

Relationship to you: 

Email Address: 

Phone Number: 

Emergency Contact Person #2

Name: 

Relationship to you: 

Email Address: 

Phone Number: 

Doctor Information

Name: 

Phone Number: 

Insurance Information

Provider: 

Policy Number: 

Hospital Preference (if any): 

Allergies (other than seasonal): 

PPD (TB Test)

Date: 

Results: 

Medications (optional): 

Date of last tetanus shot (mandatory every 8 years): 

Do you have an EpiPen?   If yes, where do you store it? 

Do you have an inhaler:   If yes, where do you store it? 

Do you have medications you would like to store in the Health Suite? 

Please include information to know if transported to an Emergency Room.  Please include conditions or medication you are currently taking if not already noted above.

 

 

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