Emergency contact and medical information form

If someone falls ill or is hurt during a shift, event or trip, you need to know who to call, and sometimes a few facts that help first aiders or emergency responders. This form collects that, and nothing more. It's for staff, volunteers and board members. For children and young people in your programs or volunteering with you, a parent or guardian should complete it.

Collect as little as possible

Health information is some of the most private information people have. Ask only for what you would actually use in an emergency, and make every health question optional.

• Emergency contacts are the main purpose. Most people will fill in only this part.
• Health information should be limited to things responders or first aiders need to know quickly, such as a serious allergy, where someone keeps an epinephrine auto-injector or inhaler, or whether they need help to leave the building. Don't ask for diagnoses, medication lists or medical history unless an activity truly requires it, such as an overnight trip.
• Leave it blank is always an acceptable answer. Say so on the form.

For employees, the Equal Employment Opportunity Commission (EEOC) says employers may ask whether people will need help in an emergency evacuation, after a job offer or through periodic surveys of all employees, as long as it's clear that self-identification is voluntary. It says the Americans with Disabilities Act requires employers to keep medical information about applicants and employees confidential, and allows sharing it with first aid and safety personnel and others who have responsibilities under the emergency evacuation plan. Many states have their own privacy laws, so check yours.

What about HIPAA? HHS's HIPAA regulations (45 CFR 160.102) apply to health plans, health care clearinghouses, and health care providers that transmit health information electronically in connection with certain transactions. If your charity isn't one of these, HIPAA doesn't govern this form, but that doesn't make the information any less sensitive: treat it with the care described below.

Store it securely

• Keep forms separate from personnel files, volunteer files and general records, in a locked cabinet or an access-restricted folder.
• Limit access to the few people who need it: the director, the person in charge of a shift or trip, and your first aiders.
• Take only what you need off-site. For a trip, carry the forms for the people on that trip in a sealed envelope, and bring them back.
• Don't share by group email or chat, and don't print it on sign-in sheets.
• Update it once a year, and when someone tells you something has changed.
• Destroy it securely when someone leaves, following your document retention policy, unless an incident means you must keep it.

See our guide to data privacy basics for more on handling personal information.