Forms and Questionnaires
Important notes about the forms:
1. Most of these forms 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 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 Physician's Office, 463 East Circle Drive, Room 346, East Lansing, MI 48824-1037.
Exposure to Bloodborne and Other Pathogens
Health Professions Students Exposure Report (PDF)
Health Care Professional Students:
Health Care Professional Student Immunizations Form (COM, CON, and CHM) (PDF) (Updated: 10/10/2012)
Health Care Professional Student Immunizations Form (Clinical Laboratory Sciences ONLY) (PDF) (Updated: 10/10/2012)
Health Care Professional Student Immunizations form (CVM Only) (PDF) (Updated: 5/16/2013)
Health Care Providers:
As of 1/27/2010, newly hired healthcare workers must make a brief appointment with Occupational Health. Call 517.353.9137 to make the appointment and bring immunization and titer records to the appointment.
Hepatitis B Surveillance Form (PDF)
Declination of Influenza Vaccination Form (PDF)
New Employee:
Exposure to Health Risks and Physical Demands (PDF through HR's Web site)
Have your supervisor complete prior to your appointment.
Operate a powered industrial truck (fork truck), tractor or overhead gantry crane:
Powered truck (fork truck), tractor, or Overhead Gantry Crane-Questionnaire (PDF-Updated: 3/22/2012)
Organophosphates and Carbamates:
(Following documents are PDFs.)
Organophosphate/Carbamate Letter
Organophosphate/Carbamate Questionnaire (Must print to fill out.)
List of Carbamate Insecticides registered for use in Michigan
List of Organophosphate Insecticides registered for use in Michigan
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)
Annual follow-up (International Students only) (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.
Work with animals or unfixed animal tissue:
Initial questionnaire (Animals or Unfixed Animal Tissue) (First time completing the form.) (PDF-Updated 2/25/2013.)
Follow-up questionnaire (Animal or Unfixed Animal Tissue) (PDF-Updated: 2/25/2013.)
Rabies Surveillance Form (PDF)
Wear a respirator:
Initial questionnaire (Wear a respirator) (First time completing the form.) (PDF)
Follow-up questionnaire (Wear a respirator) (PDF-Updated 3/3/2010)
Updated: 05/16/2013