Research Occupational Health Program Forms

Many of the forms used as part of the ROHP medical surveillance program are available below. When completed, the form(s) should be sent to ROHP either by email or faxed to the ROHP secure electronic fax number, 617-977-8788.

The ROHP medical staff will review your questionnaire(s) and contact you if additional information, testing, immunizations, or a clinic visit is required. ROHP staff will contact you directly to schedule an appointment for you to visit us at the ROHP clinic located on the Medical Campus: Evans Building, 72 E. Concord Street, 8th Floor, Room 825.

Note about privacy: Many of the forms request personal health information, which is needed to establish a baseline medical history for those persons performing research or supporting research. To protect the privacy of your medical information, these questionnaires should be sent directly to ROHP and should not be shared with your supervisor, manager, colleagues, or HR representative.

Questionnaires

ROHP is introducing revised questionnaire forms to be completed by employees engaged in or supporting research activities at Boston University. The two revised questionnaire forms are the Initial Health and the Annual Health Status Questionnaires. These questionnaire forms replace the Medical Surveillance Form, the Animal Exposure Surveillance Program Medical Evaluation Form, and the Med Surveillance for Lab Animal Exposed Annual Occupational Health Questionnaire.

In addition to consolidating the number of questionnaires used to perform medical surveillance for the research community, the purpose of the new questionnaires is to:

  • Enhance the quality and clarity of information provided to perform individual risk assessments as part of research medical surveillance.
  • Extend its use to include non-researchers who provide support to or have access to areas where research is performed with animals, agents, and hazardous materials.

Initial Health Questionnaire

The purpose of the Initial Health Questionnaire (IHQ) is to establish a baseline medical history and perform a health risk assessment for each individual. The questionnaire should be completed before work in a research environment begins. The IHQ must be completed by newly hired personnel, including contractors, students, and volunteers, who will perform research or provide support to or have access to areas where research is performed with animals, agents, and hazardous materials.

This questionnaire replaces the Animal Exposure Surveillance Program Medical Evaluation Form and Medical Surveillance Form.

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Annual Health Status Questionnaire

The purpose of the Annual Health Status Questionnaire (AHQ) is to perform a periodic health review for all personnel who have direct or indirect exposure to infectious agents, animals, animal tissues, and/or time spent in an animal care facility. The occupational health program requires periodic health reviews and updates for all personnel. The use of this form is required for the following groups:

  • Researchers and PIs listed in animal protocols
  • LASC and LACF staff
  • IACUC members and staff
  • Employees not working directly with animals but requiring access to laboratories with animals (i.e., emergency response, public safety, facilities, etc.)

The AHQ should also be completed by all laboratory staff including the principal investigator for submission of an IBC application or if adding staff to approved IBC protocols.

The AHQ replaces the Med Surveillance for Lab Animal Exposed Annual Occupational Health Questionnaire.

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OSHA Respiratory Medical Evaluation Questionnaire

The purpose of the OSHA Respiratory Questionnaire is to determine medical fitness to use respiratory protection. A surgical mask is not considered respiratory protection. If informed that your job requires respiratory protection, please complete this questionnaire.

After the respiratory questionnaire has been completed and reviewed by an ROHP medical provider, a medical clearance form will be provided to you as documentation which must be provided to EHS prior to fit testing.

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Other ROHP Forms

Accident Report & Analysis Form

The purpose of this form is to report all incidents/exposures. The report is forwarded to the Risk Management office who actively manages Boston University’s loss exposures by identifying the types of fortuitous losses faced by the University, analyzing the different types and sizes of these loss exposures, and deciding how to handle and finance these losses through a combination of insurance, self-insured retentions, risk avoidance, risk transfers, and effective claims management of the losses that do occur.

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Animal Allergy Screening Form

This form is to be completed by individuals who work with or are exposed to animals in the workplace and are allergic to animals or exhibit symptoms that may indicate allergies to animals.

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Hepatitis B Vaccine Series Authorization for Services Form

This form is to be completed by the principal investigator for individuals identified by the principal investigator and authorized by ROHP to have the Hepatitis B vaccine series.

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