UW Occupational Health Program Requisition Form for Pre ...

UW Occupational Health Program Requisition Form for Pre-Exposure ServicesThis form confirms the eligibility for the employee listed below to receive all preventive services checked.Please schedule an appointment by calling 608-265-5610. Bring this completed form with you to yourappointment located on 6 th floor at 333 East Campus Mall. Employees and supervisors should consult with theUW Occupational Health Office at 265-5000 regarding specific recommendations on recommended services.Today’s DateEmployee NameEmployee Date of BirthEmployee SexEmployee TitleEmployee Department/Lab & AddressDate of AppointmentEmployee Phone NumberEmployee EmailSupervisorSupervisor E-mailDepartment Funding StringSupervisor PhoneDept Fund Program Project Account Code

Employee Occupational Risks and ExposuresAnimal Contact exposure to vertebrate animals, animal tissues, body fluids or wastes. Please completethe Animal Contact Questionnaire prior to appointment.Infectious Agent Exposure laboratory exposure to infectious or potentially infectious materials. Pleasespecify all potential agents:o _____________________________________o _____________________________________o _____________________________________o _____________________________________o _____________________________________o _____________________________________Asbestos Abatement individuals involved in an abatement effortCommercial Driver License for those required to have a commercial driver license as part of their UWemploymentContact with Human Blood or Other Potentially Infectious Material (OPIM) includes human bodyfluids other than feces, urine, tears and sweatLaw Enforcement duties with the University Police DepartmentNoise (Work in Area of Excessive Noise) noise level defined by OSHAPatient Contact having physical or face-to-face contact with a patient, or having contact withpotentially contaminated items including (but not limited to) blood and/or body fluidsPesticide Use individuals who use pesticides as defined in the Medical Monitoring Program forPesticide UsersRespirator Use for individuals required to wear a respirator on a routine or emergency basisOther, please explain:

Services Requested:VaccinationsImmunization ReviewHepatitis B #1Hepatitis B #2Hepatitis B #3RabiesBotulinum ToxoidSmallpoxDengue FeverVaricellaMMRHepatitis A #1Hepatitis A #2InfluenzaTyphoid FeverYellow FeverJapanese EncephalitisHPV #1HPV #2HPV #3Tetanus-TdMeningococcalTetanus-TdapTB ScreeningTB Skin Test PlacementTB Skin Test ReadPositive TB Skin Test ReactorSymptom ScreenQuantiferon TB-GoldSerologic Confirmation of ImmunityHepatitis B surface AntigenRabies TiterOther-Specify:Respirator Fit Testing (includes questionnaire review)N95Other respirator (please specify)Other Medical ServicesAnimal Contact Risk Questionnaire ReviewSpirometryChest X-rayECGAudiometryLaser Eye ExamOseltamivir prophylaxisOther prophylaxis (please specify)Laboratory testing (please specify)Medical EvaluationsFitness to use a Respirator Evaluation – no asbestosexposureFitness to use a Respirator Evaluation – asbestosexposureEvaluation and prophylactic treatment for positive TBskin testHazmat physical examNuclear Reactor Medical EvaluationMedical Surveillance ConsultPesticide User ExamPregnancy Risk ConsultationOther medical evaluation (please specify):Occupational Medicine consultation regarding individual risk-Describe consultation requested andquestions to be answered:Today’s DateEmployee Signature