Employee Allergen Notification Form
Name:
*
First Name
Last Name
Department:
*
Please Select
Air Conditioning
Building Fabric
Business Development & Marketing
Central Support
Commercial
Electrical
Fire and Security
Finance
Gas
HCC
HR
IT
Maintenance Admin
Maintenance Management
Mechanical
Projects
SHE
Job Title:
*
Type of Allergy:
*
Please Select
Food
Medication
Environmental (e.g., pollen, dust)
Other
Specific Allergens: (e.g., peanuts, shellfish, penicillin, latex, etc)
*
Severity of Reaction:
*
Please Select
Mild (e.g., rash, sneezing)
Moderate (e.g., swelling, difficulty breathing)
Severe (e.g., anaphylaxis)
Do You Carry Medication for This Allergy?
*
Please Select
Yes
No
If yes, please specify (e.g., Epipen, antihistamines):
*
Steps to Take During an Allergic Reaction:
*
Any known triggers to avoid in the workplace
Any Specific accommodations you require?
Consent & Acknowledgement
By signing below, I confirm that the information provided is accurate and that I have disclosed all known allergies that may pose a risk in the workplace. I understand that this information will be kept confidential and shared only with relevant personnel to ensure a safe work environment.
Signature
*
Date
*
-
Day
-
Month
Year
Date
Submit
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