Emergency Response Form

MEDICAL EMERGENCY PREPAREDNESS

Medical emergencies, both non-lab-related and lab-related, occasionally occur while students are in a teaching lab environment. In the rare cases requiring medical evaluation or treatment, there are steps individuals can take to ensure that emergency/medical staff (paramedics, fire personnel, ER staff, etc) have the necessary information to safely assist you.

Always have some form of recognized identification (driver’s license, state ID, etc.) on your person
Have contact information for your emergency (and local) contact(s) readily available
Be prepared to provide information relating to medical conditions, allergies, medications, insurance, etc.

There may be circumstances in which your injury or illness prevents you from communicating this information to emergency responders directly. The form on the bottom of this page can be used to record important contact & medical information that can be provided to first responders on your behalf.

Recording such personal information is VOLUNTARY and the forms will not be collected. If you choose to complete the form, please fold it in half and tape it to the inside back cover of your lab notebook. Information will only be retrieved for viewing/use by emergency personnel in case of illness or injury that prevents you from communicating medical information on your own behalf.

Thanks for your assistance,

Michael Rosenbach

Undergraduate Teaching Laboratory Manager

EMERGENCY RESPONSE INFORMATION

Students & staff may, at their own discretion, provide the following information to assist emergency responders

in case of illness or injury that prevents you from communicate the information yourself.

PERSONAL INFORMATION:	EEMERGENCY CONTACT INFORMATION:(Responsible person who should be notified if you are ill/injured)
Name ______________________________________	Name ______________________________________
Address _____________________________________ ____________________________________________	Address _____________________________________ ____________________________________________
Phone ______________________________________	Phone ______________________________________
Are you over 18 years of age? __________________	Relationship _________________________________

CURRENT MEDICAL CONDITIONS: _______________________________________________________

_____________________________________________________________________________________

ALLERGIES: __________________________________________________________________________

_____________________________________________________________________________________

MEDICATIONS: _______________________________________________________________________

_____________________________________________________________________________________

DO YOU WEAR CONTACT LENSES? (important in case of eye injury) Yes / No

revised 09/2022