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  • WTAMU

    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. 


    • Part 1. Animal, Pathogen, Human/primate, Hazards 

    • Please check ALL that apply:

    • Part 2. Work Environment 

    • Other potentially infectious materials (OPIM) in humans or non-human primates:

      • All body fluids where it is difficult or impossible to differentiate between body fluids
      • Amniotic fluid
      • Any body fluid visibly contaminated with blood
      • Any unfixed tissue or organ (other than intact skin) from a human or non-human primate (living or dead) 
      • Blood, organs, or other tissues from experimental animals infected with bloodborne pathogens
      • Cell, tissue, or organ cultures 
      • Cerebral spinal fluid
      • Culture media or other solutions containing bloodborne pathogens
      • Pericardial fluid
      • Peritoneal fluid
      • Pleural fluid
      • Saliva in dental procedures (whether or not there is visible blood present)
      • Semen
      • Synovial fluid
      • Vaginal secretions

    • After completing this form, you will receive an email with information on how you can contact EHS should a need arise. (You may need to check your spam/junk folder)

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    • Part 3. Health and Respirator Use 
    •  - -Pick a Date

    • ->RECOMMENDATION:  You are overdue for Tetanus vaccination

    • --RECOMMENDATION: Tetanus vaccination is recommended every 10 years.

    • --RECOMMENDATION: The reviewer will determine if Hepatitis B vaccine is recommended for work

    • --RECOMMENDATION:  The reviewer will advise regarding eligibility for Rabies vaccine after review of your animal work.

    • --RECOMMENDATION:  A free Travel Health report can be obtained from info@uohpartners.com upon request.


    • After completing this form, you will receive an email with information on Laboratory Animal Allergy Prevention.  (You may need to check your spam/junk folder)






    • After completing this form, you will receive an email with information about reproductive hazards related to workplace exposure. (You may need to check your spam/junk folder)

    • Part 4. Signature 

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      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.

    • Clear
    • Should be Empty: