Confidential Staff Emergency Information Form

The Staff Emergency Information Form is vital in the event of an emergency.  If there is information you are not comfortable completing, please visit the nurses' office.  Per HIPAA guidelines, this information will remain confidential and secure.

* 1. Last Name

* 2. First Name

* 3. Date of Birth

 DOB

* 4. Room/Office Number

* 5. Program/Department

* 6. Cell Phone Number

* 7. Personal Email

* 8. Emergency Contact Person #1

* 9. Emergency Contact Person #2

* 10. Doctor Information

* 11. Hospital Preference (if any)

* 12. Medical Insurance Information

* 13. Allergies (other than seasonal)

* 14. Date PPD

(TB Test)

* 15. PPD Results

* 16. Medications (optional)

* 17. Date of last tetanus shot

(Mandatory every 8 years)

* 18. Do you have an EpiPen?

* 19. Do you have an inhaler?

* 20. Do you have any medications you would like to keep secure in the nurse's room?

* 21. Please include any information pertinent to know if transported to an emergency room.  Please include conditions or medications you are currently taking if not already noted.

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