Forms

BSL-3

BSL-3 Medical Questionnaire 

This medical questionnaire is required of anyone enrolled in the BSL-3 program. The Occupational Health Professional (OHP) uses this questionnaire to assess your ability to safely work with biological and chemical agents in the BSL-3 laboratory. The OHP will evaluate the information on this form and document for you and your supervisor any work restrictions or protective measures to be followed.

Drug and Alcohol Testing Program for FMCSA Covered Drivers

Paperwork for New Hires

Applicants for DOT-covered positions at the University must submit the following paperwork to University Health and Safety - Occupational Health (UHS-OH) and complete a pre-employment drug test before beginning safety-sensitive functions. Such functions include (but are not limited to) waiting to be dispatched, inspecting or servicing any commercial motor vehicle, and loading or unloading a vehicle. Current employees of the University whose job duties change to include driving functions must also complete this paperwork and a pre-employment test.

If you have any questions about the University's Drug and Alcohol Testing Program, please contact Tricia Van Ee Molbert, the Designated Employer Representative, at uohs@umn.edu or 612-626-5886.

Research Occupational Health Program Medical Requirements

Animal Exposure Questionnaire (AEQ)
The AEQ is online and can be accessed at https://eresearch.umn.edu/researchforms/animalExposure.html with your internet ID and password. If you are unable to use the online system, please contact us at uohs@umn.edu to request a paper copy.

Authorization for the Release of Health Information
Use this form to authorize your health care provider to release your immunization history to University Health and Safety - Occupational Health (UHS-OH).

Please read and complete the form carefully. You are responsible for either faxing it or mailing it to your health care providerDo not send copies of your release of health information to UHS-OH.

Note:

If you do not complete the form correctly, your health care provider will be unable to release your information to the UHS-OH. This may cause delays in updating your records and could negatively impact your clearance status.

Declination forms

If you choose to decline the rabies vaccine and/or toxoplasmosis titer, please download and complete the appropriate forms and return them to UHS-OH by fax at 612-626-9643.

Short Term Visitors Waiver of Participation in Research Occupational Health Program
For short term visitors to University laboratories/research facilities.

If you have any questions about ROHP requirements, declinations, or release of information forms, you may contact UHS-OH by email at uohs@umn.edu or by phone at 612-626-5008.

Respiratory Protection Program

Respirator Medical Evaluation Questionnaire

If you will be wearing a respirator in your work at the University, you must complete a Respirator Medical Evaluation Questionnaire. An Occupational Health Provider (OHP) will use the information in your questionnaire to assess your ability to wear a respirator safely.

We strongly prefer that you use the online version of the respirator questionnaire. To request access to the online questionnaire, please fill out and submit our Respirator Medical Evaluation Request.

Within one business day of submitting the web form, you will receive an email with a link to the online questionnaire, a username and temporary password, and instructions on scheduling your respirator fit test. Once you have completed the online questionnaire, you will receive a printable clearance certificate. If you are medically cleared for respirator use, you may then schedule your fit test. If you are not cleared, please contact us at uohs@umn.edu or by phone at 612-626-5008 for assistance with scheduling a respirator exam.