Get USDA FS-6100-17 2009

USDA Forest Service FS-6100-17 REV 08/2009 EMPLOYEE EMERGENCY DATA CARD Ref. FSM 6100 To be Completed by Federal Employees Only PRINT OR TYPE ALL ENTRIES The purpose of this form is to provide contact information for the employee and their primary emergency contact information and provide pertinent medical information in case of emergency. FIRST NAME MI LAST NAME DATE HOME ADDRESS INCLUDE ZIP CODE PHONE NO W/AREA CODE. WORK ADDRESS INCLUDE ZIP CODE IF PO BOX PROVIDE DIRECTIONS EMERGENCY CONTACT NAME SUPERVISOR S NAME ALLERGIES HEART CONDITION MEDICATIONS OTHER PHYSICIAN NAME Privacy Act Statement The information obtained in the completion of this form is to be used in case of an emergency only. Its collection and use are covered under Privacy Act System of Records USDA/FS-11 Employee Emergency Information and are consistent with the provisions of 5 USC 552a Privacy Act of 1974. Employees are asked to voluntarily provide answers the following questions. The information provided will be used in case of an emergency only. Answers will assist Forest Service officials in identifying personal contact information and specific medical conditions that may be of concern if individual employees have an accident or experience a potential medical incident that might place their health and safety at risk if not identified to first responders. Review with your personal physician any medical concerns you have that may place you or your health at risk if such an incident occurs. FIRST NAME MI LAST NAME DATE HOME ADDRESS INCLUDE ZIP CODE PHONE NO W/AREA CODE* WORK ADDRESS INCLUDE ZIP CODE IF PO BOX PROVIDE DIRECTIONS EMERGENCY CONTACT NAME SUPERVISOR S NAME ALLERGIES HEART CONDITION MEDICATIONS OTHER PHYSICIAN NAME Privacy Act Statement The information obtained in the completion of this form is to be used in case of an emergency only. Its collection and use are covered under Privacy Act System of Records USDA/FS-11 Employee Emergency Information and are consistent with the provisions of 5 USC 552a Privacy Act of 1974. Employees are asked to voluntarily provide answers the following questions. The information provided will be used in case of an emergency only. Answers will assist Forest Service officials in identifying personal contact information and specific medical conditions that may be of concern if individual employees have an accident or experience a potential medical incident that might place their health and safety at risk if not identified to first responders. Answers will assist Forest Service officials in identifying personal contact information and specific medical conditions that may be of concern if individual employees have an accident or experience a potential medical incident that might place their health and safety at risk if not identified to first responders. Review with your personal physician any medical concerns you have that may place you or your health at risk if such an incident occurs. Review with your personal physician any medical concerns you have that may place you or your health at risk if such an incident occurs. FIRST NAME MI LAST NAME DATE HOME ADDRESS INCLUDE ZIP CODE PHONE NO W/AREA CODE* WORK ADDRESS INCLUDE ZIP CODE IF PO BOX PROVIDE DIRECTIONS EMERGENCY CONTACT NAME SUPERVISOR S NAME ALLERGIES HEART CONDITION MEDICATIONS OTHER PHYSICIAN NAME Privacy Act Statement The information obtained in the completion of this form is to be used in case of an emergency only. .