University of Houston-Clear Lake
Occupational Health Program Enrollment Form
Confidential Medical Information
TYPE OR PRINT CLEARLY
Name:
Gender:  Male
 Female
Street Address:
Date of Birth:

City/State/ZIP/Country:
Your Contact Number(s):
Your email:
Your Supervisor or Sponsoring Agency:
For visitors, what is the estimated duration of your stay at UHCL?
Visiting Student Trainee  ____Months ____ Days
Visiting Scientist
 ____Months ____ Days
UHCL Department/School:
Job Title:
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
Employee Health 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. You have the option of sending the form via regular mail or sending it
via interoffice mail to the address above.
Animal / Biological Agent Contact
Please indicate the animals you work or will be working with (check the box if you work with the specified animal).
Amphibians
Gerbils
Rats
Birds
Goats
Rabbits
Cats
Guinea Pigs
Reptiles
Cattle
Hamsters
Sheep
Dogs
Mice
Swine
Ferrets
Non-Human
Primate
Wild Rodents
Fish
Poultry
Other list:
Please indicate tissue, blood, or biological agents that you work or will be working with (check the appropriate box):
Do you work with primate tissues?
Yes 
No 
Do you work in an area where primates or primate tissues are housed or handled? Yes 
Do you work with human blood products? Yes 
Do you work with animal blood products? Yes 
No 
No 
No 
Do you work with human tissue? Yes 
No 
Do you work with animal tissue? Yes 
No 
Do you work with recombinant DNA technology? Yes 
No 
If yes, does the research involve techniques in which viable, recombinant DNA-containing micro-organisms are used to infect animals
that require Bio-safety level 3 containment? Yes  No 
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Medical History
Have you had any changes in your health condition in the past year? Yes 
No 
Do you have any breathing problems? Yes 
No 
Do you have any heart problems? Yes 
No 
Have you gained or lost 20 or more pounds in the past year? Yes 
No 
Have you been told by a physician that you have an immune compromising medical condition or are you taking medications that
impair your immune system (steroids, immunosuppressive drugs, or chemotherapy)? Yes  No 
For Women: Are you pregnant, or planning to be pregnant in the next year? Yes  No 
Animal Allergies
Have you had any recent problems with the following symptoms? Yes  No 
Please indicate which symptoms you have experienced:
Condition
Yes
No
Condition
Yes
Watery or itching eyes
Shortness of breath
Runny nose
Chest tightness
Sneezing
Rash or hives
Wheezing
Chronic allergies (dust, pollen, food, mold)
Chronic cough
Asthma
No
Are these more frequent while at work? Yes  No 
Are these symptoms associated with:
Dogs

Cats

Cattle
Pigs

Primates

Rabbits 
Rats or Mice 

Horses

Bird (Feathers)

Goats

Sheep (Wool)

Guinea Pigs 
Alfalfa

Weeds

Trees


Wood

Grasses 
Mold

Chemicals

Latex
Other

List: ____________________________________________________
Have these symptoms required any treatment with over-the-counter medications (Claritin, Benadryl, decongestants, eye drops, etc.)?
Yes  No 
Have you had to wear a respirator, goggles or protective clothing to protect yourself from allergies (e.g., hay fever [rhinitis], eye
symptoms, hives or asthma) at work? Yes  No 
Have you been treated by your own physician for allergies that began at work? Yes  No 
If you suspect you may have work related allergies or have any other questions about your health status or this form, please
contact the UHCL Health Center at 281-283-2626.
ACCEPTANCE: I agree to be enrolled in the Occupational Health Program at this time. I understand that I may change my status at
any time in the future by calling the UHCL Health Center at 281-283-2626.
Signature for enrollment: ____________________________________________Date ___________________
DECLINATION: I decline to be enrolled in the Occupational Health Program at this time. I understand that I may enroll at any time
in the future by calling the UHCL Health Center at 281-283-2626.
Signature for declination: ____________________________________________Date ___________________
(Submit form in person to the UHCL Health Center, SSCB 1301)
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Medical Questionnaire Approval or Denial Form
Name:_______________________________________________________________________________________
Circle one:
Staff
Student
Faculty
Visitor
The following is to be filled out by a medical professional:
Circle appropriate status below:
1) Approved
This individual has provided adequate responses to the questionnaire and is medically approved to participate in the
Animal Care Program. Refer the individual back to the Health Center for reevaluation if the individual begins to show
symptoms of allergies or any other negative health concerns or injuries.
2) Status Waiting: Contingent on Physician’s approval
This individual has provided negative responses to the questionnaire and therefore cannot begin to participate in
the Animal Care Program. This individual must receive approval from their own personal care physician and submit
documentation (such as their professional opinion) to the Health Center before consideration into the program.
3) Reviewed by Personnel Physician.
This individual has provided to the University of Houston-Clear Lake’s Health Center the professional opinion of their
own physician to partake in the Animal Care Program.
a) Approved.
This individual is cleared of any initial negative health concerns and can participate in the program.
b) Contingent on Safety Protocol, Doctor Requirements and/or Recommendations
If the individual is to participate in the program, they must be provided engineering controls, additional
respiratory protection, etc. as to protect themselves from allergens or any other ailment.
c) Declined
Due to the severity of animal allergens and/or other health disorder, it is unsafe for this individual to participate
in the program.
Reviewed by the Office of UHCL Health and Disability Services:
______________________________________________________________________________________________
Name & Title printed
Signature
Date
Submit to Office of Sponsored Programs
Attention: Dr. Paul E. Meyers
UHCL Campus Box 44
Phone: 281-283-3015
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