POIETO INC · HR Forms

Emergency Contact Form

Confidential · Personnel file only
Complete at hire · Update as needed

This information is used only in the event of a workplace emergency. It is kept confidential in your personnel file and is not shared with other staff or participants. Please update POIETO HR if anything changes.

Employee

Full name

Job title / role

Date completed

Primary emergency contact

Full name

Relationship

Primary phone

Alternate phone optional

Email optional

Secondary emergency contact optional

Full name

Relationship

Primary phone

Alternate phone

Medical information — optional, but helpful in an emergency

Allergies or medical conditions we should know about in an emergency

Current medications (if relevant to emergency response)

Preferred hospital or doctor optional

I carry an insurance card. Location:

Authorization

I authorize POIETO INC to contact the person(s) listed above in the event of a workplace emergency. I understand this information is held confidentially in my personnel file.

Employee signature

Printed name

Date