EMPLOYEE EMERGENCY REPORTING
Reporting Person (supervisor)
*
First Name
Last Name
Reporting Person Phone Number
*
Please enter a valid phone number.
Department
*
Building/Floor
Are you reporting missing employees, employees in need of emergency assistance, or both?
*
Please Select
Missing Emplyee(s)
Employee(s) in need of emergency assistance
Both
Missing Employees
MISSING PERSON(S)
How many missing employees are you reporting? If you need to report more than 10 missing employees, please select "5" here, add and submit the data for the first 10 employees, then open an additional JotForm to report additional missing employees.
*
Please Select
1 missing employee
2 missing employees
3 missing employees
4 missing employees
5 missing employees
6 missing employees
7 missing employees
8 missing employees
9 missing employees
10 missing employees
Employee 1 (missing person)
Employee 1 (missing person)
*
First Name
Last Name
Employee 1 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 2 (missing person)
Employee 2 (missing person)
*
First Name
Last Name
Employee 2 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 3 (missing person)
Employee 3 (missing person)
*
First Name
Last Name
Employee 3 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 4 (missing person)
Employee 4 (missing person)
*
First Name
Last Name
Employee 4 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 5 (missing person)
Employee 5 (missing person)
*
First Name
Last Name
Employee 5 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 6 (missing person)
Employee 6 (missing person)
*
First Name
Last Name
Employee 6 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 7 (missing person)
Employee 7 (missing person)
*
First Name
Last Name
Employee 7 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 8 (missing person)
Employee 8 (missing person)
*
First Name
Last Name
Employee 8 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 9 (missing person)
Employee 9 (missing person)
*
First Name
Last Name
Employee 9 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Employee 10 (missing person)
Employee 10 (missing person)
*
First Name
Last Name
Employee 10 Phone Number
Please enter a valid phone number.
Last Known Location
*
Date & Time Last Known Location Was Reported
Emergency Assistance Needed
EMERGENCY ASSISTANCE NEEDED
Click to add a person whose location is known, but is in need of rescue or emergency medical assistance. If you need to report more than 5 employees, add the first 5 employees to this JotForm and submit, then open an additional JotForm(S) to report additional employees.
How many employees are you reporting as injured or in need of emergency assistance? If you need to report more than 10 employees in need of emergency assistance, select 10 from the options below, add and submit the data for the first 10 employees, then open an additional JotForm to report additional employees.
*
Please Select
1 employee
2 employees
3 employees
4 employees
5 employees
6 employees
7 employees
8 employees
9 employees
10 employees
Employee 1 (person in need of rescue or emergency medical assistance)
Employee 1 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 1 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 1
*
Date & Time Location Was Reported
Employee 2 (person in need of rescue or emergency medical assistance)
Employee 2 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 2 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 2
*
Date & Time Location Was Reported
Employee 3 (person in need of rescue or emergency medical assistance)
Employee 3 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 3 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 3
*
Date & Time Location Was Reported
Employee 4 (person in need of rescue or emergency medical assistance)
Employee 4 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 4 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 4
*
Date & Time Location Was Reported
Employee 5 (person in need of rescue or emergency medical assistance)
Employee 5 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 5 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 5
*
Date & Time Location Was Reported
Employee 6 (person in need of rescue or emergency medical assistance)
Employee 6 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 6 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 6
*
Date & Time Location Was Reported
Employee 7 (person in need of rescue or emergency medical assistance)
Employee 7 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 7 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 7
*
Date & Time Location Was Reported
Employee 8 (person in need of rescue or emergency medical assistance)
Employee 8 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 8 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 8
*
Date & Time Location Was Reported
Employee 9 (person in need of rescue or emergency medical assistance)
Employee 9 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 9 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 9
*
Date & Time Location Was Reported
Employee 10 (person in need of rescue or emergency medical assistance)
Employee 10 (person in need of rescue or emergency medical assistance)
*
First Name
Last Name
Employee 10 Phone Number, if known
Please enter a valid phone number.
Current Location of Employee 10
*
Date & Time Location Was Reported
Submit
Print
Submit
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