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EMPLOYEE P ERSONAL P ROFILE F ORMProfile Information: The information requested in this questionnaire is voluntaryand confidential, and is not to be used for any purpose other than during an actualemergency. The contents of this questionnaire must be kept in a sealed envelope in a

secure area and it will not be opened unless in the case of an actual emergency. Thecontents of this questionnaire and your photograph will be updated annually duringyour performance evaluation.

Personal Identifying Information:

Your name:

Nickname or other names used:

Employment classification:

Employment location:

ermanent residence:

Telephone:

!econdary residence:

Telephone:

"ther employment, if applicable:

#ate of birth: $ $ lace of birth:

Name of hospital: %other&s name:

'ace: !e(: )omple(ion:

*eight: +eight:

*aircolor:

Eye color:

!cars$marks$tattoos:

*obbies:

re your fingerprints and a current photograph on file with this institution-Yes No

Your Family And Emergency Notification Information:

%arital status: nniversary date: $ $

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Name of spouse$roommate: Nickname:

Name of child:/irth date: $ $

Persons To Contact In Case Of Emergency: Name:

hone:

ddress:'elationship:

Name:hone:

ddress:'elationship:

Name:hone:

ddress:'elationship:

Your Immediate Close Relatives:

Name:

hone: ddress:

'elationship:

Name:hone:

ddress:'elationship:

Name:hone:

ddress:'elationship:

Other Persons iving Or !or"ing In Your #ousehold:

Name:'elationship:

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Name:'elationship:

Name:'elationship:

Name:'elationship:

Your $otor %ehicles:

Year: %ake:%odel:

)olor:

0icense: #riven by:

Year: %ake:

%odel:)olor:

0icense: #riven by:

Year: %ake:%odel:

)olor:

0icense: #riven by:

Your $edical Information:

hysician:

ddress:hone:

hysician:

ddress:hone:

*ospital:

ddress:hone:

/lood type: llergic to:

%edical condition1s2 requiring treatment or medication:

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Treatment or medication:

%edical condition1s2 requiring treatment or medication:

Treatment or medication:

I authorize my physician s! to release confi"ential information in thee#ent of an emer$ency situation re%uirin$ treatment&

!igned:#ate:

EMPLOYEE:

fter completing this form, place the form into the envelope provided and seal theenvelope. +rite your name 1last, first, middle initial2 and !ocial !ecurity number onthe face of the envelope. #eliver the sealed envelope to your reviewer. lease includeany other information you feel is necessary on a separate page, to be included withthis profile.

RE'IE(ER:

Ensure that the employee&s envelope is securely sealed and completed as indicated.3nitial and date the face of the envelope and store it in a secure area.

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