Revised on
10/31/19 01:30pm

Occupational Health Services Forms

Animal Bite Information

Animal Bite or Scratch Reporting Form


Audio Questionnaire

Completed by the employee as part of the requirements for the annual hearing conservation program


UCD Occupational Health Services is a covered entity under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which requires health care providers to notify patients of their right to privacy of their Protected Health Information (PHI). This rule also gives patients many rights regarding the use and disclosure of their PHI. Patients are informed of their rights by being given a Notice of Privacy Practices.

Medical History for New Patients

Completed by patients who have never been seen for medical services at Occupational Health Services.

Request & Authorization for Medical Services

Completed by the department to ensure that the medical services provided are appropriate, requested by the department, and the interdepartmental billing reflects the services rendered.   

Respirator Questionnaire

Completed by employee required to wear respirator

Travel Questionnaire

Completed by the employee requesting Travel Immunization Services 

Medical Waiver

Completed by the employee that is required to have medical services provided that pertain to their job but they decline services