Emergency Response Form

Emergency Response Information

Lab workers may (at their own discretion) use this form to record information to be used in case of emergencies. Print this page, fill in any parts that concern youor your conditions, and carry it with you.

Lab students: please fold the form and tape it INSIDE THE BACK COVER OF YOUR LAB NOTEBOOK. Revise, replace or discard the form as needed. If a student is ill/injured and cannot respond, this information will be provided to emergency responders (paramedics/hospital personnel).

STUDENT NAME ___________________________________
Address ___________________________________________
___________________________________________________
Phone _____________________________________________
UCSD ID # _________________________________________

EMERGENCY CONTACT NAME
(i.e., a responsible person who should be notified if you are ill/injured)
_______________________________________
Address _______________________________
_______________________________________
Phone _________________________________
Relationship ____________________________

MEDICAL INFORMATION:
(List ALL allergies (food, medication, plants, bites, etc.), ongoing medical concerns, and history of serious illness/seizures/fainting.)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Do you wear contact lenses? __Yes __No

CURRENT MEDICATIONS: Copy information from medication labels for all medicines - prescription & over-the-counter.
Name of medication	Dose	Frequency
example:__ tetracycline _____ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________	___ 250 mg _________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________	_____ twice/day ________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________