The information requested in this questionnaire about your health status will be used only to detect diseases or bodily dysfunction due to your work with wildlife in the field or your work with animals in the UM Laboratory Animal Resources facility before you would normally seek medical care. Your responses to this questionnaire are considered confidential; they will be reviewed by an occupational medicine physician and stored in an off-campus medical office to ensure the security of your confidential information.

Please download the form, complete and email it to the IACUC Manager at IACUC@mso.umt.edu or mail directly to the physician's office listed on the form.

This questionnaire is mandatory.

Download Risk Assessment Form (Word document)