Employee Emergency Work Authorization

EMPLOYEE EMERGENCY WORK AUTHORIZATION

This Employee Emergency Work Authorization authorizes performance of temporary duties during an emergency or extraordinary operational condition. Employer Name: Location/Facility: Effective From: To:

Personal Information

Position and Assignment Information

Reporting Manager: Assignment Start Date: Expected End Date:

Emergency Assignment Duties

Travel Required: If checked, provide travel details:

Safety, Training and Compliance

Employee must comply with all emergency policies, safety protocols, and any additional training required prior to performing duties. The employee acknowledges that certain assignments may involve increased risk of exposure to hazards and consents to follow all employer-mandated infection control, safety, and decontamination procedures.

Employee acknowledges receipt of and agreement to the conditions set forth in this authorization and confirms that they have been offered training appropriate to the duties assigned: Training Received

Compensation, Timekeeping and Expenses

Time must be recorded in the employer's timekeeping system. Overtime and premium rates will be applied in accordance with company policy and applicable law. Any out-of-pocket expenses must be pre-authorized and will be reimbursed upon submission of itemized receipts.

Duration and Termination

This authorization is temporary and may be modified or terminated at the employer's discretion without prior notice where operational needs or safety concerns require. Continued employment remains subject to existing employment terms, including at-will status where applicable.

Employment History (Most Recent Two Employers)

Education

References (Professional)

Legal Disclosures and Employee Certification

At-Will Employment: Nothing in this authorization alters the at-will employment relationship between the employee and employer where such relationship exists. Either party may terminate employment or this emergency assignment at any time, with or without cause, unless otherwise required by law.

Equal Employment Opportunity: Employer maintains a policy of equal opportunity and non-discrimination. Emergency assignments will be administered without regard to protected characteristics.

Authorization to Verify: I authorize the employer to contact my prior employers and references, and to conduct any background or credential checks necessary to verify my qualifications for the emergency assignment. I understand that falsification of information may result in disciplinary action up to and including termination.

Certification: I certify that all information provided on this form is true and complete. I acknowledge receipt of this Emergency Work Authorization and agree to comply with its terms and all employer policies applicable to the assignment.

Consent: I consent to the verification of employment, references, and any lawful background checks necessary for this assignment.

Acknowledgment of Risk and Indemnification

The employee acknowledges that performance of emergency duties may involve risks beyond normal job duties. To the extent permitted by law, the employee releases the employer from liability for injury or illness that is the direct result of following employer-mandated emergency procedures, except to the extent caused by the employer's gross negligence or willful misconduct.

The employee agrees to follow all safety directives, use required PPE, report incidents immediately, and cooperate with any employer investigations related to emergency operations.

Applicant Certification (Acknowledgment)

I certify that the information provided in this authorization and any attached documentation is true and accurate to the best of my knowledge. I understand the nature of the temporary assignment, the terms of compensation, and my obligations with respect to safety and timekeeping.

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