University of Texas Employee Health Clinical Services Occupational Health Program Enrollment Form Confidential Medical Information TYPE OR PRINT CLEARLY Name: Date of Birth: Gender: Male Female Street Address: City/State/ZIP/Country: Your Contact Number(s): Your email: Your Supervisor or Sponsoring Agency: For visitors, what is the estimated duration of your stay at UTH? Visiting Student Trainee ____Months ____ Days Visiting Scientist ____Months ____ Days Job Title: UTH Department/School: CONFIDENTIALITY STATEMENT: This form requests that you provide personal health information that is protected by University policy and State and Federal law. Your rights to the confidentiality of your personal health information will be strictly maintained by Employee Health Services. Your information will be used or disclosed in accordance with those policies and laws only to the minimal extent necessary for your treatment or business operations. You are not required to disclose this information and may decline enrollment at the end of this form. Animal / Biological Agent Contact Please indicate the animals you work or will be working with (check the box if you work with the specified animal). Amphibians Gerbils Rats Other list: Birds Goats Rabbits Cats Guinea Pigs Reptiles Cattle Hamsters Sheep Dogs Mice Swine Non-Human Ferrets Wild Rodents Primate Fish Poultry Please indicate tissue, blood, or biological agents that you work or will be working with (check the appropriate box): Do you work with primate tissues? Yes No Do you work in an area where primates or primate tissues are housed or handled? Yes No Do you work with human blood products? Yes No Do you work with animal blood products? Yes No Do you work with human tissue? Yes No Do you work with animal tissue? Yes No Do you work with recombinant DNA technology? Yes No If yes, does the research involve techniques in viable, recombinant DNA-containing micro-organisms are used to infect animals that require Bio-safety level 3 containment? Yes No Medical History Have you had any changes in your health condition in the past year? Yes No
University of Texas Employee Health Clinical Services Occupational Health Program Enrollment Form Confidential Medical Information TYPE OR PRINT CLEARLY Name: Date of Birth: Gender: Male Female Street Address: City/State/ZIP/Country: Your Contact Number(s): Your email: Your Supervisor or Sponsoring Agency: For visitors, what is the estimated duration of your stay at UTH? Visiting Student Trainee ____Months ____ Days Visiting Scientist ____Months ____ Days Job Title: UTH Department/School: CONFIDENTIALITY STATEMENT: This form requests that you provide personal health information that is protected by University policy and State and Federal law. Your rights to the confidentiality of your personal health information will be strictly maintained by Employee Health Services. Your information will be used or disclosed in accordance with those policies and laws only to the minimal extent necessary for your treatment or business operations. You are not required to disclose this information and may decline enrollment at the end of this form. Animal / Biological Agent Contact Please indicate the animals you work or will be working with (check the box if you work with the specified animal). Amphibians Gerbils Rats Other list: Birds Goats Rabbits Cats Guinea Pigs Reptiles Cattle Hamsters Sheep Dogs Mice Swine Ferrets Non-Human Primate Wild Rodents Fish Poultry Please indicate tissue, blood, or biological agents that you work or will be working with (check the appropriate box): Do you work with primate tissues? Yes No Do you work in an area where primates or primate tissues are housed or handled? Yes No Do you work with human blood products? Yes No Do you work with animal blood products? Yes No Do you work with human tissue? Yes No Do you work with animal tissue? Yes No Do you work with recombinant DNA technology? Yes No If yes, does the research involve techniques in viable, recombinant DNA-containing micro-organisms are used to infect animals that require Bio-safety level 3 containment? Yes No Medical History Have you had any changes in your health condition in the past year? Yes No
Occupational_Health_Program_Enrollment_Form_06.19.18.docx