Health Surveillance Questionnaire

The purpose of this questionnaire is to obtain an individual health history for employees working with animals and other significant biological agents. It will be used in conjunction with individual protocol risk assessments to evaluate appropriate medical surveillance needs and to determine appropriate individual personal protective equipment (PPE) needs.

Note: If your research only involves exposure to invertebrates, do not complete this survey. Rather, please contact Environmental, Health and Safety Services for assistance at 231-4034.

CONFIDENTIALITY STATEMENT: This form requires 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 Environmental, Health and Safety 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. Information that is electronically transmitted on this form will be maintained in a secure environment. If you wish to complete this form non-electronically, please contact EHSS at 231-4034. This is a secure website.