OCCMED Forms

Occupational Medicine Program Forms
Revised February 2008

The need for any of the following forms depends on the department’s identification of specific job duties covered by the University of Florida’s Occupational Medicine Program. This can be done both during the hire process and during a change of duties process.

For those individuals hired on a specific position, the job duties are identified by position number in the PeopleSoft Human Resource position information on the UF Hr Position Dta tab. (Navigation: Organizational Development, Position Management, Maintain Positions/Budgets, Add/Update Position Info)

For those individuals hired with no position attached (OPS or volunteers), the job duties are identified outside of PeopleSoft on the form Job-Related Health Risk Checklist for Individuals Not On Positions (see INOP Form below).

All prospective employees and volunteers will be required to sign the UF HIPAA Authorization to Use or Disclose Protected Health Information form which allows job-related, duty-specific information to be shared with specified UF Departments. (See HIPAA Release Form below.)

JOB DUTY	PREPLACEMENT	PERIODIC

All on list (prospective employees and volunteers)	HIPAA Release Form
All on list (OPS and volunteers)	lNOP Form (Individuals Not On Positions)
All on list	Supervisor Checklist for determining need for health assessment
All on list	Candidate Waiver Request
All on list (For outside the Gainesville area)	Fax Cover Sheet for Medical Record Transfer
All on list except Animal Contact, Contact with Human Blood, Noise and Patient Contact	Preplacement Physical Exam and Medical History
Animal Contact	Risk Assessment for Animal Contact Risk Assessment for Animal Contact	Renewal Risk Assessment for Animal Contact Renewal Risk Assessment for Animal Contact
Asbestos Work	Initial Medical Questionnaire	Periodic Medical Questionnaire
Contact with Human Blood or OPIM	Training and Vaccination Form
Law Enforcement	Hepatitis A Vaccination Form
Noise	New Hire Questionnaire	Medical Update Form
Patient Contact	Preplacement Screening Patient Contact Form HIPAA Release Form TB Surveillance Form
Patient Contact for Residents	Preplacement Screening Patient Contact Form for Residents HIPAA Release Form Medical History Questionnaire for N-95 Filtering Face Piece Respirators TB Surveillance Form
Respirator Use	Initial Medical Questionnaire for Respirator Use Medical History Questionnaire for N-95 Filtering Face Piece Respirators	Annual/Periodic Medical History Questionnaire for Respirator Use
Scientific Research Diving	Medical Evaluation of Fitness for SCUBA Diving Report SCUBA Diving Medical History	Medical Evaluation of Fitness for SCUBA Diving Report SCUBA Diving Medical History