Form – Emergency Contact – Universal Staffing

Emergency Contact and Medical Information for Employee

Employee's Name *

Date of Birth *

Contact #1 (Name and Relationship) *

Home Phone

Work / Cell Phone *

Address *

City, Province, Postal Code *

Contact #2 (Name and Relationship)

Home Phone

Work/Cell Phone

Address

City, Province, Postal Code

Additional Alternative Emergency Contacts (if needed)

Contact #3 (Name and Relationship)

Home Phone

Work/Cell Phone

Address

City, Province, Postal Code

Contact #4 (Name and Relationship)

Home Phone

Work/Cell Phone

Address

City, Province, Postal Code

Medical Information

Hospital / Clinic Preference

Physician's Name

Insurance Company

Phone Number

Policy Number

Allergies/Special Health Considerations. Please list all known medical problems that we should be aware of.

I authorize all medical and personal information contained on this form to be used to assist Universal Staffing in contacting the above noted emergency persons and to assist in arranging emergency treatment should I be injured at work and need to be transported to a local medical hospital or clinic for treatment. This waiver applies only in permitting Universal Staffing permission to use this information in the event of an emergency.

Employee's Signature *

Universal Staffing will retain this confidential information as part of the employees file & will destroy this information by means of shredding at the employee request or after the period of time whereby the employee is no longer actively employed.

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