The University of Texas at El Paso

The University of Texas at El Paso

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The University of Texas at El Paso

Occupational Health Medicine Questionnaire Permit Request

The purpose of this form is to obtain information from individuals working with hazardous materials or potentially hazardous materials at UTEP. This form requires that you provide work history and some general health information. Your rights to the confidentiality of your personal health information will be strictly maintained by the Student Health Center and the Department of Environmental Health and Safety (EH&S).

Requester

* Required
* Required
* Required
* Required

Permit Date & Time

* Required
* Required
* Required
* Required

Location

* Required

    Information

    A. Animal Use/Work

    B. Biohazard Use/Work

    C. Work Environment

    D

    E

    Add Supporting Documents

    Add files to upload as supporting documentation along with your permit request.