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Emergency contact:
Name _________________________________________________
address _______________________________________________
______________________________________________________
Phone number _________________________________________
Primary care physician:
Name _________________________________________________
address _______________________________________________
______________________________________________________
Phone number _________________________________________
Blood type: __________________________________________
Special medications: __________________________________
______________________________________________________
Health (physical or mental) issues affecting work:
______________________________________________________
______________________________________________________
SOURCE: Adapted from Ron Krannich, Ph.D., The Re-Entry Employment and Life Skills Pocket Guide (Manassas Park: Impact Publications), page 3. Copyright 2009. All rights reserved. Copying strictly forbidden.
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