Forms and Instructions

BSL-3

Drug and Alcohol Testing Program for FMCSA Covered Drivers

Research Occupational Health Program Medical Requirements

Respiratory Protection Program

BSL-3

BSL-3 Medical Questionnaire

The purpose of this form is to obtain information about your personal health and work exposures. This information will be used by the Occupational Health Professional (OHP) to make an accurate assessment of your ability to safely work with biological and chemical agents in the BSL-3 laboratory. The OHP will evaluate the information on this form and document for you and your supervisor any work restrictions or protective measures to be followed. If restrictions and/or protective measures are required, it is the University’s expectation that you will comply.

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Drug and Alcohol Testing Program for FMCSA Covered Drivers

Paperwork for New Hires

Applicants for DOT-covered positions at the University must submit the following paperwork to the Office of Occupational Health and Safety and complete a pre-employment drug test before beginning safety-sensitive functions. Such functions include (but are not limited to) waiting to be dispatched, inspecting or servicing any commercial motor vehicle, and loading or unloading a vehicle. Current employees of the University whose job duties change to include driving functions must also complete this paperwork and a pre-employment test.

• Doctor's Authorization to Operate a Commercial Motor Vehicle While Using a Controlled Substance: A doctor must complete this form if the applicant or employee has been prescribed a controlled substance. If the applicant/employee is not currently taking any prescription drugs, he or she must complete the form.
• Information for Applicants for DOT-covered Positions: Federal law requires applicants/employees to indicate whether they have previously refused to be tested or received a positive test result on any pre-employment test for any other DOT employer.
• Release of Information: Authorizes the release of an applicant's/employee's DOT testing records from a previous employer to the University.
• University Drug and Alcohol Policy for FMCSA-covered Employees (current policy as of 6/1/2010): Applicants/employees must sign the second page of the policy to acknowledge that they have received the policy. Please note that policy revisions are in process and will be communicated to affected departments in the next three months.

If you have any questions about the University's Drug and Alcohol Testing Program, please contact KrisAnne Weiss, the Designated Employer Representative, at weis0135@umn.edu or (612) 624-4103.  

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Research Occupational Health Program Medical Requirements

Animal Exposure Questionnaire (AEQ)
The AEQ is now online and can be accessed by logging in to ROHP at https://eresearch.umn.edu/rohp/ with your internet ID and password. If you are unable to use the online system, you may download the AEQ here, fill it out, and follow the printed directions on the first page to submit it to the Office of Occupational Health and Safety. Contact the Office of Occupational Health and Safety for assistance at uohs@umn.edu.

Authorization for the Release of Health Information
Use this form to authorize your health care provider to release your immunization history to the Office of Occupational Health and Safety.

Please read and complete the form carefully. You are responsible for either faxing it or mailing it to your health care provider. Do not send copies of your release of health information to the Office of Occupational Health and Safety. 

Note:

If you do not complete the form correctly, your health care provider will be unable to release your information to the Office of Occupational Health and Safety. This may cause delays in updating your records and could negatively impact your clearance status.

Declination forms

If you choose to decline the rabies vaccine and/or toxoplasmosis titer, please download and complete the appropriate forms and return them to Office of Occupational Health and Safety via fax at 612-626-9643.

• Rabies Information Sheet and Declination Form for Rabies Vaccination
• Toxoplasmosis Information Sheet and Declination Form for Toxoplasmosis Titer 

Short Term Visitors Waiver of Participation in Research Occupational Health Program
For short term visitors to University laboratories/research facilities.

If you have any questions about ROHP requirements, declinations, or release of information forms, you may contact the Office of Occupational Health and Safety by email at uohs@umn.edu or by phone at 612-626-5008.

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Respiratory Protection Program

Respirator Medical Evaluation

If you will be wearing a respirator in your work at the University, you must complete a Respirator Medical Evaluation. The purpose of this evaluation is to obtain information about your personal health and work exposures. An Occupational Health Provider (OHP) will use this information to make an accurate assessment of your ability to safely wear a respirator.

The Respirator Medical Evaluation is now available online. In order to request access to the Respirator Medical Evaluation, please fill out and submit our web form.

You will receive an email with a link to the online Respirator Medical Evaluation and a temporary password. The first time you log in to the system you will be required to reset your password. Upon completion of the online questionnaire, you will receive a printable certificate indicating your Respirator Recommendations. If you are medically cleared for respirator use, you may then schedule your fit test. You will receive instructions on how to schedule your fit test upon completion of the evaluation.

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