Medical Monitoring Program for Animal Use Facilities

Medical Monitoring for Animal Users (SOP)

Instructions to Submit Enrollment Forms for the Medical Monitoring Program for Animal Research

Click to Complete the forms below.  Forms B-F must be completed to enroll.

FORM

FORM NAME

INSTRUCTIONS

Send To

FORM A

Fax Cover Sheet

  • Enter date
  • Write your name on the RE: line
  • Write the total number of pages in fax.

Use only if faxing

FORM B

Medical Referral Form

  • Complete only the following sections:
  • Employee/participant name
  • Department
  • Date
  • Supervisor/PI

US Healthworks

Must have Signature of supervisor to receive care on site at US Healthworks

FORM C

Hazard Assessment Form

  • Complete the entire form with the assistance of your PI, if necessary.

Henry Hutchison (EHS)

hutchins@fau.edu

FORM D

Initial Health Questionnaire

  • Complete the entire form.

US Healthworks

FORM E

Medical Screening Consent/Declination Form

  • Complete this form in its entirety.  

US Healthworks

FORM F

Animal Contact Clearance Form

  • Complete all sections with the exception of the “Physician’s Statement” section.

US Healthworks

 

Submission Instructions:

  • Fax your completed form to US Healthworks using the Fax Cover Sheet (FORM A); OR scan and e-mail your MMAP to jteron@concentra.com   (please do not use a photo as it may not be readable).
  • If you know you would like to receive vaccinations and other screening procedures available, please make an appointment at US Heathworks at the locations at the bottom of FORM B. 
  • If you work at our Jupiter or Harbor Branch locations, please contact the EH&S Department at 561-297-3809 for a referral to a medical service near your location.
  • Please contact the Henry Hutchison with the EH&S Department at hutchins@fau.edu or 561-297-3809 with any questions regarding this process. 
Click here to FAU Veterinary Services (Comparative Medicine)

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 Last Modified 5/17/18