EECS Emergency Contact Form

Who Should Be Contacted In Case of Emergency?

Employee's Name

Phone Number:
Street Name, P.O. Box:
City, State, Zip:

Designation of Personal Physician

Workers' Compensation Injuries

PERSONAL PHYSICIAN is defined as an M.D. or osteopathic physician who has previously directed the medical treatment of them employee, and who retains the employee's medical records, including his or her medical history.

Physician's Name:
Physician's Phone Number:
Physician's Address: