Employee Contact Information Form

Employee Contact Information

Name

First Last

Position Title*

Unit*

Immediate Supervisor*

Primary Work Site*

Cicero
Des Plaines
Ford Heights
North District/Rolling Meadows
Oak Forest Health Center - Admin Bldg.
Oak Forest Health Center - Bldg. A
Oak Forest Health Center - Bldg. B
Robbins
Southwest District/Bridgeview

Work Email Address*

Desk Phone*

Work Mobile (if applicable)

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact Numbers

During an emergency, if CCDPH needs to contact you, what three numbers would you prefer to be called in order of your preference? Select the appropriate check box for each number.

First Contact Number*

First Contact Number Type*

Home
Personal Mobile
Wk Mobile
Desk Phone

Second Contact Number*

Second Contact Number Type*

Home
Personal Mobile
Wk Mobile
Desk Phone

Third Contact Number*

Third Contact Number Type*

Home
Personal Mobile
Wk Mobile
Desk Phone

Emergency Contact Numbers

Please list two individuals that we may contact for emergency purposes only.

First Emergency Contact Name*

First Last

First Emergency Contact Phone*

First Emergency Contact Relationship to You*

Second Emergency Contact Name*

First Last

Second Emergency Contact Phone*

Second Emergency Contact Relationship to You*

Vehicle Information

Please provide Make, Model, Color & License Plate Number of the car(s) you use for work.

Make*

Model*

Color*

License Plate #*

Additional Vehicle Informaiton

Make

Model

Color

License Plate #

Distance from primary work site

Do you live Within 5 Miles?*

Yes
No

Dual Employment Information

Are you employed outside of CCDPH?*

Yes
No

If yes, please provide emergency work contact phone number:

Language skills other than English

Language type

Speaking

Fair
Good
Fluent

Reading

Fair
Good
Fluent

Writing

Fair
Good
Fluent

Language type

Speaking

Fair
Good
Fluent

Reading

Fair
Good
Fluent

Writing

Fair
Good
Fluent

Employee Prophylaxis Information

In the event of a public health emergency, CCDPH may be required to provide employees and other individuals residing in the home with prophylaxis in the form of medications or vaccine. The information below will assist in our planning efforts:

Number of individuals in your household over 100 lbs. (Including yourself)*

Number of individuals in your household under 100 lbs. (Including yourself)*

Authorization

Employee Authorization Statement*

By checking this box I am agreeing that all information on this form is correct.

I verify that all the information above is true and, if applicable, authorize all changes noted to my personal data profile and employee contact information. I agree to submit updated information for any field on this form whenever the current information has changed. I have/will also submit a copy of this completed form to my Service Unit Director.