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