Visual Arts Department Emergency Contact Information Form

Emergency contact information for faculty, graduate students, visiting graduate scholars, visiting scholars and staff.

Privacy Notification

The State of California Information Practices Act of 1977, effective July 1, 1978, requires the University to provide information to individuals who are asked to supply information about themselves.

The principal purpose for requesting the information on this form is to contact the designated person in case of serious illness, accident or death. University policy authorizes maintenance of this information.

Other than name, furnishing the information requested on the form is voluntary. There is no penalty for not completing this form. Information furnished on this form may be used by various University departments for contacting relatives or a designated representative, filing for benefits and payment of benefits.

Individuals have the right to review their own records in accordance with Staff and Academic personnel policies and procedures.
Employee Name Employee Name First Last
Employee Email
Employee Type
Employee ID
PID
I decline to provide emergency contact information.

I decline to provide emergency contact information. Yes
Name of person to contact in case of emergency:
Emergency Contact Name Emergency Contact Name First Last
Emergency Contact Relatoinship
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
Emergency Contact Email
Emergency Contact Language Spoken
Emergency Contact Address Emergency Contact Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Alternate Contact In Case of Emergency (optional)
Alternate Emergency Contact Name Alternate Emergency Contact Name First Last
Alternate Emergency Contact Relationship
Alternate Emergency Contact Phone Alternate Emergency Contact Phone - ### - ### ####
Alternate Emergency Contact Email
Alternate Emergency Contact Language Spoken
Alternate Emergency Contact Address Alternate Emergency Contact Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Visual Arts Department Emergency Contact Information Form

Visual Arts Department Emergency Contact Information Form

Privacy Notification

Name of person to contact in case of emergency:

Alternate Contact In Case of Emergency (optional)