Medical Monitoring Program for Animal Use Facilities

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)