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Field Team Review and Emergency Data <br /> I have read and reviewed the most recent revision <br /> Date <br /> of the Health and Safety Plan (HASP) for the <br /> Project <br /> I understand the information contained therein and will <br /> Site <br /> comply with all aspects of the HASP. <br /> Name : <br /> Signature: <br /> - ------ -------- <br /> Date: <br /> This information is in case of emergency only: <br /> Social Security #: _ <br /> Person(s) to notify in case of Emergency: <br /> Relationship: <br /> Daytime Phone #: <br /> Name of Physician : Phone #: <br /> Medical Coverage : <br /> Employee Date of Birth: <br /> * Known Allergies: <br /> *Known Medical Conditions: <br /> *any known allergies or medical conditions that physicians should be made aware of before <br /> medical attention is given (i. e. allergic to penicillin) . <br />