WTAMU Occupational Health Enrollment

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WTAMU

Environmental Health and Safety Occupational Health Program Enrollment Form
Why am I being asked to complete this enrollment? West Texas A&M University is required by TAMUS, State and Federal regulations to provide an occupational health program for all individuals who may have occupational risk. Please answer the questionnaire in Part I to determine your occupational risk status. If you have questions or need assistance, please contact Academic Research Environmental Health and Safety (AREHS) at (806) 651-2740 or ar-ehs@wtamu.edu

Helpful hint on mobile devices: you may be able to use microphone to dictate answers.
First Name*
Last Name*
Email*
example@example.com
Phone Number*
(Area Code) Phone Number
UIN:
If you do not have a UIN, check below:

I do not have a UIN
What is your Age?
years old
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Job (check all that apply)*

WTAMU Student or Trainee (non veterinary)WTAMU Veterinary Student or TraineeWTAMU EmployeeVisitorOther
Type in your department below*
What is your primary role? (eg. Principal Investigator, Animal Care, Veterinarian, Researcher, Technician, etc)
Are you paid for your work in this position?

YesNo

Part 1. Animal, Pathogen, Human/primate, Hazards
Please check ALL that apply:
Animal
Pathogens
Human and Primate
Hazards
Required double check. Choose one below.*

I have checked the risks above that apply to my workNothing above applies. continue to SUBMIT.

Part 4. Signature
Please certify by signing that you have completed this form to the best of your knowledge for review by the Occupational Medicine provider. Then complete by pressing SUBMIT.
Please sign your name below*

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