Employee Emergency Information Page 2
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1
2Employee Emergency Contact and Medical Form
:
Continued
(For HR Use Only)
Employee’s Name
Position
Comments (include any special medical or personal information you would want an Emergency care provider to know –
or special information:
Allergies:
Allergies to
Medication:
Medication currently
taken:
Other Information for
the use of a Doctor or
Nurse:
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
Employee’s
Signature
Date:
Please return this form to the Human Resources Department.
Middletown City School District
Revised: November 2015
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Parent category: Business