University of Michigan Hospitals U-M Occupational Health Services New Employee Health Assessment Form

NEW REG & TEMP EMPLOYEES MUST BE CLEARED IN ALL IMMUNIZATION AND MEDICAL SURVEILLANCE CATEGORIES PRIOR TO MTV ORIENTATION. HAVE THEM CALL OHS TO SET UP THEIR APPOINTMENT.

This form is NOT intended for printing purposes! Please complete the entire form and submit to OHS electronically by clicking on the submit button at the end of the form. Fill out all fields completely.

Note: Aramark employees must be processed through Occupational Health Service.

Employee First Name:
Employee Last Name:
Employee Job Title:
Employee home/cell phone number:* (with area code)
Employee Email*
Employee Date of Birth:
Employee ID:*/unique name/ OR Employee SS #*
(Employee ID can be found in Wolverine Access)
Does employee have patient contact, go in patient rooms for any reason, or process patient specimens? Yes No
Based on the IP&E Policy, does this employee need to be fit tested for an N95/PAPR? Yes No
Will the employee require Ishihara testing? (Color blindness) Yes No

Will the employee be working in the Hyperbaric Chamber?

Yes No
Is this person a Survival Flight nurse or pilot or a member of the SWAT team? Yes No

If Yes please indicated which in this box

This employee will be paid by: (choose as many as apply) Hospitals/Health Centers
Campus
Medical School
Other
Temporary Employee
Regular Employee

Hire Date:
Org Code (Dept. ID):
Department Name:
Department Phone:
Hiring Supervisor:
Comments:
Sender Name:*
Sender Email:*
 

NEW REG & TEMP EMPLOYEES MUST BE CLEARED IN ALL IMMUNIZATION AND MEDICAL SURVEILLANCE CATEGORIES PRIOR TO MTV ORIENTATION. HAVE THEM CALL OHS TO SET UP THEIR APPOINTMENT.