Occupational Health Program Records

Occupational Health Program Records
This form should only be used by Baylor College of Medicine students and employees for Occupational Health Program in Houston.

Temple Campus: Please do not submit records, await instruction.

If you are a patient of Baylor and need to request your records, OHP does not maintain these records. Requests should be sent to: ROI@bcm.edu or fax (713) 798-1464.
Name (as known within the Baylor system)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
BCM ID (if applicable)
Purpose of Document Submission*

Submitting immunizationsOther
Program Name

Medical School (M.D.)Physician Assistant (PA)Orthotics and Prosthetics (O & P)Genetic Counseling (GS)Doctor of Nursing Practice Program (DNP)Graduate School of Biomedical Sciences (PhD, MSBS or BSHEq)Summer Program (SMART, PSI)
Is this your first submission?

YesNo
I am a...
Student status

Has startedHas not started
Employee status

CurrentPrevious
Attachments (5 MB or smaller)*

Limit of 5 per submission. PDF only. 5MB or smaller.
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