Occupational Safety & Health

Medical Surveillance Questionnaire:

The Medical Surveillance form is to be used for those employees wanting (or for those employees identified as required) to participate in the university’s Occupational Health and Safety Medical Surveillance Program.  The Medical Surveillance Program is optional for most personnel but IS STRONGLY RECOMMENDED for anyone working with animals. 

The benefits of participating in the program by filling out this form include:

• Medical conditions are reviewed when performing a risk assessment of work areas or activities.

• Establishes a baseline for future comparison.

• There is no charge to you personally for participation in the Occupational Health and Safety Medical Surveillance Program.

You may elect to complete this form and participate in the Occupational Health and Safety Medical Surveillance Program at any time during your work at the university.   Please contact Steve Farrell, Director, Environmental Health and Safety, at ehs@wright.edu or at ext. 2215.

The Medical Surveillance form may be filled out, printed, and faxed to us at 937-775-3761

or,

The Medical Surveillance form may be filled out, printed, and delivered to us at 047 Biological Sciences II.