{"id":525,"date":"2017-09-08T15:11:02","date_gmt":"2017-09-08T19:11:02","guid":{"rendered":"https:\/\/cws.charlotte.edu\/stage-research\/initial-enrollment-and-update-forms\/"},"modified":"2024-02-06T15:56:36","modified_gmt":"2024-02-06T20:56:36","slug":"initial-enrollment-and-update-forms","status":"publish","type":"page","link":"https:\/\/cws.charlotte.edu\/stage-research\/departments\/office-research-protections-and-integrity-orpi\/animal-care-use\/occupational-health-0\/","title":{"rendered":"Initial Enrollment and Update Forms"},"content":{"rendered":"\n

Occupational Health Program – Submission Instructions and Forms<\/h2>\n\n\n\n

All individuals who work with animals and\/or animal tissues or who are exposed to them at UNC Charlotte are required by the Institutional Animal Care and Use Committee (IACUC) to enroll in the Occupational Health Medical Surveillance Program (OHMSP) prior to initiating their work or being granted access to the Vivarium per the Occupational Health Medical Surveillance Policy<\/a>. For more on the animal care\/use occupational health program, please click here.<\/a><\/p>\n\n\n\n

Initial Health History Form \u2013 with fax cover sheet<\/strong><\/td>Word<\/a><\/td><\/tr>
Interim Health Status Update Form \u2013 with fax cover sheet<\/strong><\/td>Word<\/a><\/td><\/tr>
Annual Health Update Form \u2013 with fax cover <\/strong>sheet<\/strong><\/td>Word<\/a><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

Initial Enrollment<\/h2>\n\n\n\n

The following steps will ensure initial enrollment into the OHMSP:<\/p>\n\n\n\n

STEP 1:<\/strong> Electronically complete an Initial Health History Form<\/a>. Print the completed form and fax cover sheet. Sign and date the last page of the form.<\/p>\n\n\n\n

STEP 2: <\/strong>Fax your Initial Health History form using the completed fax cover sheet to the Occupational Health Physician, Fax (704) 631-1202 (HIPAA-compliant secure line).<\/p>\n\n\n\n

STEP 3: <\/strong>The Occupational Health Physician will review your Initial Health History form and conduct a risk assessment.<\/p>\n\n\n\n

STEP 4:<\/strong> The Occupational Health Physician will communicate the result of his medical evaluation via a Medical Clearance form to be routed to the following individuals: the enrollee; the Principal Investigator\/Supervisor managing the enrollee\u2019s animal lab work; the Director, Laboratory Animal Resources; and the IACUC Coordinator. Effective 1\/1\/2014, all new enrollees must receive clearance from the Occupational Health Physician BEFORE commencing work with animals\/animal tissue or accessing the Vivarium.<\/p>\n\n\n\n

NOTE: Initial physical examinations are required for those who fall in the \u201cHigh Risk\u201d category, or as directed by the Occupational Health Physician as a condition for medical clearance to work in the Vivarium or other campus workspaces where animal use\/exposure occurs.<\/p>\n\n\n\n

PRIVACY NOTICE: This clearance determination will never include specific health-related information about the enrollee. Enrollees\u2019 protected health information will not be disclosed. However, the clearance determination may include recommendations for immunizations, use of a respirator, and\/or extra personal protective equipment, and the date of most recent tetanus immunization. Both the Occupational Health Physician and the specific UNC Charlotte units\/employees identified above are legally bound to comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations.<\/p>\n\n\n\n

Any self-reported information contained in the Basic Health History Form, the Annual Update to the Basic Health History Form, and\/or the Health Status Update Form, as well as any other medical information generated by the Occupational Health Physician related to an individual\u2019s enrollment and continued standing in the Occupational Health Program will become part of that individual\u2019s confidential occupational health medical record retained at the office of the Occupational Health Physician.<\/p>\n\n\n\n

Interim Health Status Changes<\/h2>\n\n\n\n

The Interim Health Status Update Form<\/a> should be completed and routed to the Occupational Health Physician when an enrollee needs to report:<\/p>\n\n\n\n