Forms and Questionnaires
Important notes about the forms:
1. Most of these forms, except for the Sample Source Protocol, are Adobe Acrobat files requiring Adobe Acrobat Reader to view them. Download the Acrobat Reader from Adobe's Web site.
2. Many of the forms you can complete on-line.
3. If you choose to complete the forms on-line it would be best if you print the forms and either fax or mail the completed forms to the University Physician's Office in lieu of sending via an email message. Doing so will safeguard any private and medical related information you enter on the forms.
Please print and complete the appropriate form(s) prior to your appointment.
If you would like to:
1. Fax a completed form to (517)355-0332.
2. Mail a completed form to University Office, 347 Olin Health Center.
New Employee:
Exposure to Health Risks and Physical Demands (PDF through HR's Web site)
Have your supervisor complete prior to your appointment.
Work with animals or unfixed animal tissue:
Initial questionnaire (Animals or Unfixed Animal Tissue) (PDF)
Follow-up questionnaire (Animal or Unfixed Animal Tissue) (PDF)
Rabies Surveillance Form (PDF)
Wear a respirator:
Initial questionnaire (Wear a respirator) (PDF)
Follow-up questionnaire (Wear a respirator) (PDF)
Operate a powered industrial truck (forktruck), tractor or overhead gantry crane:
Questionnaire (PDF)
Health Care Professional Students:
Health Care Professional Student Immunizations Form (PDF)
Health Care Providers:
Health Care Worker Immunization Form (PDF)
Hepatitis B Surveillance Form (PDF)
TB Symptom Monitor (also for Students):
(For employees/students with a previous reactive TB test) - MUST PRINT
Initial (first time completing the form) (PDF)
Annual follow-up (PDF)
Exposure to Blood Bourne and Other Pathogens
Health Professions Students Exposure Report (PDF)
Vaccine Information:
Vaccine Information Sheets by Centers for Disease Control and Prevention. These sheets provide detailed disease and vaccine information, such as possible side-effects, for immunizations such as Hepatitis B and Rabies.
Updated: 10/8/09