Can this agreement be electronically signed?

Yes. Electronic signatures meet ESIGN (15 U.S.C. ch. 96) and UETA requirements for enforceability when intent, consent, attribution, and record retention are present. For consumer-facing or healthcare records, ensure required consumer disclosures and HIPAA safeguards before e-signing.

Is notarization or witness required?

Typically notarization is not required for a Good Samaritans Agreement, but employer or state rules may request notarization or witnesses for added evidentiary weight. Check applicable state law and company policy; use RON where permitted for convenience.

What personal data should be protected?

Protect health information, medical records, and any insurer-sensitive details under HIPAA when applicable. Limit internal disclosure to necessary personnel, redact nonessential identifiers in shared copies, and keep audit logs showing who accessed or exported the document.

How long should we retain executed agreements?

Retain while the employee is active, then for at least three years after termination to meet IRS and audit requirements (IRC §6501(a)); retain health-related records for six years per HIPAA (45 CFR §164.530(j)). Adjust for state law or legal holds.

Can we require medical releases?

Yes, where necessary for claims or treatment reimbursement, include a narrowly tailored medical release and document explicit employee consent. For federally protected health information, ensure HIPAA-compliant authorizations and disclose the right to withdraw consent as required by ESIGN consumer rules.

How can eSignature platforms help manage these agreements?

Use eSignature platforms to enforce required fields, capture timestamps and IP addresses, retain an audit trail, conditionally show privacy clauses, and export signed PDF/A copies. Ensure chosen vendor supports encryption, retention controls, and any required BAA for HIPAA compliance.

Electronic Signature
Templates
HR
Employee Good Samaritans Agreement

Employee Good Samaritans Agreement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EMPLOYEE GOOD SAMARITANS AGREEMENT

This Employee Good Samaritans Agreement (Agreement) is entered into between Employer Name: and Employee Name: Effective Date:

Personal Information

Full legal name Home address Primary phone Email address

Position Information

Job title Department Reporting manager

Employment start date: Salary / Rate:

Employment status: Full-Time Part-Time Temporary/Contract

Employment History (Most Recent)

Employer 1 — Company name Title / Position

From: To:

Primary responsibilities Reason for leaving

Employment History (Prior)

Employer 2 — Company name Title / Position

From: To:

Primary responsibilities Reason for leaving

Education

Highest degree or certification Institution

Graduation / Completion date:

References (Professional)

Reference 1 — Name Reference 2 — Name Reference 3 — Name

Legal Disclosures

At-Will Employment: The parties acknowledge that, unless otherwise stated in a separate written agreement signed by an authorized representative of Employer, employment with Employer is at-will and may be terminated by either party at any time, with or without cause or notice.

Equal Opportunity: Employer provides equal employment opportunity to all employees and applicants without regard to protected characteristics. Decisions regarding recruitment, hiring, promotion, discipline, compensation and termination are made without unlawful discrimination.

Good Samaritan Duties, Consent and Release

1. Purpose and Scope: Employee volunteers to provide emergency assistance, first aid, cardiopulmonary resuscitation (CPR), use of an automated external defibrillator (AED), and other reasonable emergency care to coworkers, visitors, or members of the public encountered in the course of employment when immediate action is necessary to prevent serious injury or death. Such assistance is voluntary and outside the scope of normal job duties unless specifically required by Employer.

2. Training and Certification: Employee certifies whether they currently hold relevant training or licenses as indicated below. Employer may require training prior to permitting certain interventions.

I am currently trained/certified in first aid/CPR/AED
I request Employer-provided training (if available)

3. Voluntary Action and No Additional Compensation: Employee acknowledges that any emergency assistance provided as a Good Samaritan is voluntary and does not entitle Employee to additional compensation, benefits, or advancement unless a separate agreement is executed.

4. Waiver and Release: To the fullest extent permitted by law, Employee releases Employer, its officers, directors, agents and employees from claims, damages, liabilities and costs arising out of or related to Employee's voluntary provision of emergency assistance, except in the case of gross negligence or willful misconduct by Employer.

5. Indemnification: Employee agrees to indemnify and hold harmless Employer from third-party claims arising solely from Employee's negligent acts while providing voluntary emergency assistance, subject to applicable law and Employer policies.

6. Emergency Medical Treatment Authorization: If Employee is injured while providing emergency aid, Employer is authorized to arrange for emergency medical treatment. Employee will be responsible for costs of personal medical treatment unless otherwise required by law or Employer policy.

7. Reporting and Documentation: Any provision of emergency assistance must be promptly reported to Employee's supervisor and documented in accordance with Employer incident reporting procedures.

8. Compliance with Policy and Law: Employee agrees to act in accordance with applicable laws, professional standards (if licensed), and Employer safety and emergency response policies when rendering aid.

Authorization to Contact and Background Checks

By checking the box below, Employee authorizes Employer and its agents to contact prior employers and references listed above and to conduct criminal background checks, motor vehicle records checks, and other pre- or post-employment screenings as permitted by law. Employee understands that any adverse information may be considered in decisions regarding training, assignment, or continuation of privileges to act as a Good Samaritan under this Agreement.

I authorize contact with prior employers and consent to background checks

Applicant / Employee Certification and Authorization

I certify that all information provided in this Agreement and any attachments is true, complete and correct to the best of my knowledge. I understand that making false statements or omissions may result in disciplinary action up to and including termination of employment. I further certify that I have read, understood, and agree to comply with the terms of this Employee Good Samaritans Agreement.

I certify that the information provided is true and I agree to the terms above

Additional remarks (optional)

Miscellaneous Provisions

Governing Law: This Agreement will be governed by and construed in accordance with the laws of the state or jurisdiction in which Employer maintains its principal place of business, without regard to conflict of law principles.

Severability: If any provision of this Agreement is held invalid or unenforceable, the remainder of the Agreement will remain in full force and effect.

Modification: No amendment or modification of this Agreement will be effective unless in writing and signed by both Employer and Employee.

Employer Representative:

Printed Name:

By:

Date:

Employee:

Printed Name:

By:

Date:

What an Employee Good Samaritans Agreement Is

An Employee Good Samaritans Agreement is a written workplace document that records an employee’s voluntary provision of immediate assistance to a colleague, customer, or member of the public during an emergency and the employer’s acknowledgement of that action. The agreement clarifies the circumstances that triggered intervention, documents any limited indemnity or expense reimbursement the employer provides, and records consent to recordkeeping or medical release when required. It is used to align expectations, reduce post-incident disputes, and create a clear administrative record for human resources or insurance purposes.

Why employers use this agreement

Use an Employee Good Samaritans Agreement to clarify responsibilities after on-the-job assistance, limit misunderstandings about liability or compensation, document consent for medical information sharing when needed, and provide a uniform record useful for HR reviews and insurance reporting.

Who typically completes and manages these agreements

Typical users include employers, HR professionals, safety officers, and supervisors responsible for incident response and personnel records.

Human resources teams responsible for incident reporting, investigations, disciplinary records, and personnel file updates
Safety officers and supervisors documenting first aid, emergency response details, and corrective actions taken
Risk management or insurance contacts evaluating liability exposure, expense reimbursement, and claim documentation

These agreements are practical for any employer that wants consistent handling of spontaneous assistance incidents and clear administrative records for future review.

Core components to include in the agreement

Core components of an Employee Good Samaritans Agreement outline scope, consent, reimbursement, liability, confidentiality, and recordkeeping obligations between employer and employee.

Scope

Defines types of emergencies and permitted assistance, the expected response level, boundaries of employer-authorized interventions, and whether the action occurred in the course of employment or as a personal act.

Consent

Records employee consent for medical treatment disclosure, photo release, or sharing of incident details with insurers and investigates, specifying the limited recipients and parties.

Indemnity

States any employer indemnification, limitation of employer liability, or agreement to cover reasonable medical or travel expenses directly related to the assisted person’s care immediately.

Reimbursement

Specifies whether the employer reimburses medical costs, transportation, lost wages, or other out-of-pocket expenses, including required receipts, submission timelines, and limits or caps on covered amounts.

Confidentiality

Requires handling of any health or incident information in compliance with HIPAA when applicable, restricts internal disclosure beyond necessary personnel, and specifies permitted reporting to insurers or regulators.

Recordkeeping

Describes document retention, who maintains the record, access controls, and how long the agreement and related incident notes will be stored for HR or legal purposes.

Step-by-step: completing the agreement

Follow these steps to complete an Employee Good Samaritans Agreement accurately and ensure HR and legal records are consistent.

01

Identify Incident: Record date, time, location, and immediate actions taken.
02

Collect Witnesses: List witness names and contact details with brief statements.
03

Document Medical: Obtain consent for medical information release when required.
04

Sign & File: Employee and employer sign, then file in HR.

How the agreement moves from draft to archive

Standard routing shows how to route, sign, and store the agreement for compliance and auditability.

Prepare Document: Complete fields and attach incident supporting documents.
Authorize Signers: Specify employee, manager, HR, and any witness roles.
eSign or Notarize: Choose electronic signature or notarization when required.
Archive: Store final PDF with audit trail and access controls.

Configuring an online workflow for this agreement

Configure an online workflow that assigns fields, authentication, and retention settings before sending for signature.

Setup Field and Configuration Options	Configuration
Signer Authentication Level and Methods	Email, SMS, or KBA; choose per risk
Required Fields and Conditional Field Logic	Mark mandatory fields; show additional fields when triggered
Retention Periods and Access Permissions	Set storage duration and role-based access controls
Notifications, Reminders, and Audit Trail	Enable email reminders and preserve detailed audit logs

Platform and technical considerations for eSubmission

Confirm your e-sign platform supports required integrations, secure storage, and accepted file formats before deployment.

Formats: PDF, DOCX, and image attachments supported
Integrations: Connectors for HRIS, Google Workspace, and NetSuite
Security: TLS in transit; AES-256 at rest

How to save and what supporting documents to include

Final signed agreements should be exported in secure, long-term formats and accompanied by supporting incident evidence and consent records for complete administrative files.

PDF/A

Export an archived PDF/A copy to preserve pagination and embedded signatures; include the audit trail metadata so the document, timestamps, and signer attribution are reproducible for compliance or legal review.

Searchable PDF

Save an OCRed, searchable PDF of the agreement and attachments to enable quick retrieval, redaction where necessary, and efficient responses to internal or regulatory information requests.

Native Files

Keep original editable files (DOCX) in a secure document management system with version history to support amendments, forensic preservation, and traceability of changes before finalization.

Supporting Docs

Attach witness statements, medical receipts, photos, incident logs, and any correspondences; maintain a single indexed folder with an audit log for cohesive evidentiary access internal.

Practical scenarios where these agreements matter

Real-world scenarios illustrate how Employee Good Samaritans Agreements prevent disputes, guide reimbursements, and preserve privacy-sensitive medical information after workplace assistance events.

Hospitality Incident

A hotel employee administered CPR to a guest in the lobby after a cardiac event; the employer documented the actions immediately with witnesses and time stamps.

Agreement clarified expense reimbursement and information sharing.
Because the incident record included a signed Employee Good Samaritans Agreement, HR processed medical reimbursement promptly, limited unnecessary disclosures consistent with HIPAA, and insurers accepted the documentation without additional affidavits, avoiding prolonged claim disputes.

Manufacturing First Aid

A line worker provided first aid to a coworker after a laceration; company safety team recorded the event with photos, witness names, and treatment notes.

Agreement set reimbursement and training follow-up.
The agreement specified eligible expenses and documentation requirements; the employer paid covered costs promptly, scheduled retraining, and retained the signed record in the employee file, which simplified OSHA review and internal safety analysis.

Common preparation mistakes to avoid

Failing to document incident time, witness names, and exact actions taken leads to ambiguous records that complicate internal reviews and external insurance inquiries.
Using vague reimbursement language such as 'reasonable expenses' without caps or submission rules creates disputes over eligible costs and payment timelines.
Omitting HIPAA-considerate language when health information may be shared can trigger privacy concerns and potential regulatory penalties for improper disclosures.
Allowing unsigned or initial-only acknowledgements, or not confirming employer representative authority, undermines enforceability and complicates later investigations or claims handling.

Risks of incomplete or incorrect agreements

Invalid Record: May weaken evidentiary value

Increased Liability: Employer exposed to greater claims

Insurance Denial: Claims rejected for insufficient documentation

HIPAA Violation: Unauthorized disclosure risks civil penalties

Worker Trust: Damaged employee relations and morale

Regulatory Scrutiny: OSHA or state investigators may probe

Essential information to capture on the form

Employee Name: Full legal name as on ID

Employee ID: Company badge or personnel number

Incident Date/Time: MM/DD/YYYY and HH:MM with timezone

Location: Street address or precise site description

Assistance Description: Concise actions taken and observed outcomes

Signatures: Employee and authorized employer representative

Timing and deadlines to observe

Key timing considerations for completing, signing, reporting, and retaining an Employee Good Samaritans Agreement after an incident.

Report Incident to Supervisor Within 24 Hours:

Notify supervisor and HR as soon as possible, ideally within one business day.

Complete Agreement and Sign Promptly:

Finalize details, collect signatures, and attach witness statements within 72 hours.

Submit Insurance or Medical Claims Quickly:

File receipts and claim forms per insurer timelines; delays can reduce coverage.

Retain in HR File per Policy:

Keep the executed agreement in personnel file and incident folder per retention policy.

Review During Investigations or Claims:

Provide copies to investigators or legal counsel when requested during a review.

How this agreement differs from related forms

Compare related documents to select the right form: agreements, waivers, incident reports, and medical consent each serve distinct functions and legal effects.

Criteria	Good Samaritans Agreement	Release Waiver	Incident Report	Medical Consent
Primary Purpose	document assistance	limit liability	record facts	authorize treatment
Legal Effect	acknowledgement	liability waiver	informational record	consent for care
Notarization Typical		sometimes recommended		sometimes required
Privacy Considerations	can include hipaa terms	may include phi waiver issues	contains phi	includes hipaa authorization

Practical tips to improve accuracy and speed

Adopt consistent templates and digital workflows to reduce errors, speed signings, and ensure compliance with privacy and recordkeeping requirements.

Use a standardized company template for all incidents

Maintain a single version-controlled Employee Good Samaritans Agreement template that includes required fields, conditional privacy language, and signature placeholders; this reduces drafting variance, simplifies auditing, and speeds HR processing during incident follow-up.

Collect witness contact and brief written statements promptly

Obtain witness names, contact details, and short signed statements within 72 hours while memories are fresh; timestamp and attach these to the agreement to strengthen investigative records and support any insurance or legal inquiries.

Use clear reimbursement rules with receipts and limits

Define eligible expense categories, required documentation, submission deadlines, and maximum reimbursable amounts. Reimbursement procedures should describe approval workflows, expected payment timelines, and how disputes over costs will be escalated and resolved.

Securely store executed agreements with limited access

Store signed agreements in a secure records system with role-based access, encryption at rest, and audit logging. Retain per policy, export copies for legal or insurance review, and establish deletion protocols consistent with retention schedules and applicable laws.

Frequently asked questions about execution, privacy, and retention

Common questions about completing, signing, and storing an Employee Good Samaritans Agreement, including eSignature and privacy considerations.

Need help? Contact support

Can this agreement be electronically signed?
Yes. Electronic signatures meet ESIGN (15 U.S.C. ch. 96) and UETA requirements for enforceability when intent, consent, attribution, and record retention are present. For consumer-facing or healthcare records, ensure required consumer disclosures and HIPAA safeguards before e-signing.
Is notarization or witness required?
Typically notarization is not required for a Good Samaritans Agreement, but employer or state rules may request notarization or witnesses for added evidentiary weight. Check applicable state law and company policy; use RON where permitted for convenience.
What personal data should be protected?
Protect health information, medical records, and any insurer-sensitive details under HIPAA when applicable. Limit internal disclosure to necessary personnel, redact nonessential identifiers in shared copies, and keep audit logs showing who accessed or exported the document.
How long should we retain executed agreements?
Retain while the employee is active, then for at least three years after termination to meet IRS and audit requirements (IRC §6501(a)); retain health-related records for six years per HIPAA (45 CFR §164.530(j)). Adjust for state law or legal holds.
Can we require medical releases?
Yes, where necessary for claims or treatment reimbursement, include a narrowly tailored medical release and document explicit employee consent. For federally protected health information, ensure HIPAA-compliant authorizations and disclose the right to withdraw consent as required by ESIGN consumer rules.
How can eSignature platforms help manage these agreements?
Use eSignature platforms to enforce required fields, capture timestamps and IP addresses, retain an audit trail, conditionally show privacy clauses, and export signed PDF/A copies. Ensure chosen vendor supports encryption, retention controls, and any required BAA for HIPAA compliance.

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