Employee Critical Incident Contact Information

    Critical incident contact information will be deleted from the system at the end of each year. Please submit a new form after January 1st.

    Your Name (first and last):

    Your Email:

    Your Division:

    Emergency Contact:

    Who would you like us to contact in the event that you are involved in an emergency:

    First and Last Name:

    Relationship:

    Cell or Home Phone:

    Work Phone:

    Work Location:

    Other Emergency Contact:

    Is there someone else you would like us to notify or assist in addition to the emergency contact:

    First and Last Name:

    Relationship:

    Cell or Home Phone:

    Work Phone:

    Work Location:

    Support Co-Worker:

    Which WCSO co-worker would you want to respond and remain with you for support following a critical incident:

    First Choice (first and last name):

    Second Choice (first and last name):

    Notification Co-Worker:

    Is there a WCSO co-worker that you would like to assist with notification of your family, if feasible:

    First Choice (first and last name):

    Second Choice (first and last name):

    Friend or Clergy:

    Is there a friend or clergy member that you would like to assist you and/or your family in the event of a critical incident or death:

    First Choice:

    Second Choice