FIU MEDICAL SURVEILLANCE PROGRAM HEALTH QUESTIONNAIRE FOR EMPLOYEES WITH ANIMAL CONTACT 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your name, date, Panther ID, position, date of birth, and contact details. Ensure accuracy as this information is crucial for your medical provider.
3. Proceed to the Occupational History section. Answer questions regarding your job duties and any previous occupational illnesses or injuries. Be thorough in detailing any animal species you may work with.
4. In the Latex History section, respond to questions about any allergic reactions you may have experienced. This is important for your safety and health assessments.
5. Complete the Infectious Diseases section by indicating any relevant medical history related to tuberculosis and other infectious diseases. Provide dates for tests and treatments where applicable.
6. Finally, fill out the Medical History section carefully. Include current health problems, medications, allergies, and any necessary work accommodations.

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