Employee Allergy Disclosure Form
Employee Full Name
Position
Date
1. Allergens Disclosure
Please indicate if you have any allergies to the following common food allergens:
Egg
Milk
Wheat
Soy
Peanuts
Tree Nuts
Fish
Shellfish
Sesame
Other
If 'Other', please specify:
Describe your allergic reaction and any preventative steps or medication required:
2. Medical Attention Consent
In case of an emergency, do you consent for medical attention to be sought on your behalf?
Yes
No
Emergency Contact Name
Emergency Contact Phone Number
3. Declaration
I confirm the information provided is true and complete.
Employee Signature
Date