Employee Emergency Contact Information
AD-1894 (Rev. 04/14)
(LAST) (FIRST) (MI)
Branch/Division
Street Address
(CITY) (STATE) (ZIP)
Employment Status
In case of an emergency, please contact:
1st Choice
Relationship
(NAME)
(Optional)
2nd Choice
Relationship
(NAME)
In case of a medical emergency, please contact:
Note: This information will only be used if you (as the employee) are unable to contact your Physician or Medical Facility.
Physician's Name
Street Address
(Street) (CITY) (STATE) (ZIP)
Medical Facility
In case of a medical emergency, is there any medical information that may be necessary to be released for your safety?
Please print this form, sign and forward to the Human Resources Office
EMPLOYEE SIGNATURE
DATE
Name
(Optional)
Supervisor's Name
I authorize CalSTRS to contact the aforementioned individuals in case of an emergency
If yes, please specify special instructions here (e.g. allergies to medication):
EMPLOYEE SIGNATURE DATE
CC: Supervisor
Offical Personnel Folder
Employee Information
Voluntary medical information
Yes
No
I decline to provide medical information
I authorize CalSTRS to release medical information in case of an emergency
(Street) (CITY) (STATE) (ZIP)
Work Phone
Home Phone
Cell Phone
Work Location
1st Number
2nd Number 3rd Number
3rd Number2nd Number
1st Number
Phone
Phone
