Employee emergency contact form
A one-page emergency contact form with two contacts, their relationship and phone numbers, a doctor and any medical notes the employee wants on file.
- ๐บ๐ธ US format ยท Letter size
- Free
This is a sample form. Check that the terms and pay match federal and state labor rules and your company policy.
Fill in what you need. The preview updates as you type.
What you type is not saved on our server.
Store it as a confidential medical record
The medical notes are voluntary, and once written down they are medical information. The ADA requires employers to keep medical information in a separate confidential file, apart from the personnel file, and to share it only with people who need it in an emergency.
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Employee Emergency Contact Form
| Employee | Jordan Lee | Department and title | Marketing, Associate |
|---|---|---|---|
| Work or mobile phone | (555) 010-0000 | jordan.lee@example.com | |
| Home address | 123 Main St, Apt 4 Austin, TX 78701 | ||
Primary emergency contact
| Name | Taylor Kim | Relationship | Spouse |
|---|---|---|---|
| Phone | (555) 010-0202 | Alternate phone | (555) 010-0203 |
Secondary emergency contact
| Name | Sam Park | Relationship | Brother |
|---|---|---|---|
| Phone | (555) 010-0404 | Alternate phone | ย |
Physician or clinic (optional)
| Doctor or clinic | Dr. Casey Nguyen, Hill Country Family Medicine | Phone | (555) 010-0606 |
|---|
Medical notes (voluntary)
This section is voluntary. Share only what you want emergency responders to know, such as allergies, conditions or medications. Leaving it blank has no effect on your employment.
| Allergies, conditions, medications | Allergic to penicillin. Carries an inhaler for asthma. |
|---|---|
I confirm this information is correct and will give Human Resources an updated form when it changes. I give permission for the company to share it with emergency responders and my emergency contacts when needed. October 5, 2026 Employee signature: Jordan Lee To: Human Resources | |
How to use it
Type the employee's contact details and two emergency contacts, each as name | relationship | phone | alternate phone. The doctor line and the medical notes are optional; the form says so on the page, so nobody feels pushed to disclose a condition. Sign and date, and the form prints on one Letter page.
Hand it out with the new hire paperwork and ask for a new one once a year or whenever a phone number changes. Managers need a copy they can reach fast, so many companies keep the contact half in a binder or a shared drive and the medical notes in the confidential file only.
Things to watch
Ask for the information you would use in an emergency and nothing else. Relationship and phone are enough for a contact; a home address for the contact is not needed. Check that the primary contact is someone who answers the phone during work hours.
Calculators that go with this
Frequently asked questions
Can my employer require me to list a medical condition?
No. The medical section is voluntary and says so on the form. Share what would help a paramedic, such as a severe allergy or a condition like diabetes, if you are comfortable doing so.
What if I only have one contact?
Leave the secondary contact empty and the boxes print blank. A coworker or neighbor can be the second contact if you have no family nearby.
Who at the company sees this form?
Human Resources and the direct manager, so someone can act quickly. Medical notes should be in the confidential file that only HR opens.
Is what I type saved anywhere?
No. Everything stays in your browser and nothing is sent to our server. If you refresh the page it is gone, so print, save a PDF or download the DOCX when you are done.