Division of Experimental Medicine (DEM) Emergency Contact Form

All information provided in this form will remain confidential and will only be used in case of an emergency by the administration in our Division. If you have any questions please email us at ExperimentalMedicine@ucsf.edu.

Employee Information

Employee First Name

Employee Last Name

Employee Home Phone

If you do not have a home phone please type "N/A."

Employee Cell Phone

If you do not have a cell phone please type "N/A."

Employee Other Phone

If you do not have another phone please type "N/A."

Employee Home Address

123 Main Street, Apt. 3, San Francisco, CA 94110

Employee Alternative Email Address

Ex: @gmail.com, @aol.com, @yahoo.com, etc.

Employee Primary Division

Please write out your division name. Example if you are an employee in the Division of Experimental Medicine you would write "Experimental Medicine."

Lab Association

Employee Supervisor Name

First and last name

Special Needs

Ex: Allergies, etc. or please type "N/A."

Special Skills in Case of Emergency

Ex: CPR certification, languages, etc. or please type "N/A."

Primary Emergency Contact information

Primary Contact First Name:

Primary Contact Last Name:

Primary Contact Relationship to Employee:

Primary Contact Work Phone:

If no work phone please type "N/A."

Primary Contact Personal Phone:

Ex: Home or cell phone

Secondary Emergency Contact information

Secondary Contact First Name:

Secondary Contact Last Name:

Secondary Contact Relationship to Employee:

Secondary Contact Work Phone:

If no work phone please type "N/A."

Secondary Contact Personal Phone:

Ex: Home or cell phone

Date Audited/Updated

Enter today's date.

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