Forms and Questionnaires

(Mainly for employees

Updated: 7/23/08)

Important notes about the forms is listed on this page.

1. The forms open and work best in Internet Explorer.
2. Forms that have the option to e-mail to the University Physician's Office only work if your computer is connected to and configured to work with an e-mail client such as Outlook or Groupwise.

Please complete an e-mail or print the appropriate form(s) prior to your appointment. If you would like to fax a completed form please fax to (517)355-0332.

• New Employee:
  • Exposure to Health Risks and Physical Demands
    • Should be completed by your supervisor prior to your appointment
• Work with animals or unfixed animal tissue (updated 4/16/08 - complete, print, and fax to UPhys Office)
  • Initial questionnaire
  • Follow-up questionnaire
• Wear a respirator - MUST PRINT and fill out
  • Initial appointment and New Employee Health History (updated 1/29/08)
  • Follow-up appointment (updated 1/29/08)
• Drive a mobile powered industrial truck (forklift or gator):
  • Questionnaire (Updated 7/26/07)
• Health Care Providers:
  • Health Care Worker Immunization Form
• Sample Source Protocol
• TB Symptom Monitor (also for Students): (For employees/students with a previous reactive TB test) - MUST PRINT and fill out
  • Initial (first time completing the form)
  • Annual follow-up
• 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: 7/23/08 1:57 PM

Note: 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 free of charge from Adobe's Web site