Medical Monitoring Program for Animal Research

Animal Research Health and Safety Plan  New!

Animal Research Medical Monitoring Enrollment Packet New!

Instructions to Submit Enrollment Forms (from link above) for the Medical Monitoring Program for Animal Research

The packet above must be completed to enroll.

FORM NAME    (From Packet above)


Send To

Hazard Assessment Form

  • Complete the entire form with the assistance of your PI, if necessary.
Send to Josanne Hollingsworth-Maida with the  EHS Department

Initial Health Questionnaire

  • Complete the entire form.


Medical Screening Consent/Declination Form

  • Complete this form in its entirety.  


Medical Referral Form

Click here to for just this form.

  • Complete only the following sections:
  • Employee/participant name
  • Department
  • Date
  • Supervisor/PI
  • Concentra
  • Must have Signature of supervisor to receive care on site at Concentra

Animal Contact Clearance Form

  • Complete all sections with the exception of the “Physician’s Statement” section.


Annual Health Questionnaire for Work with Animals (Required Annually)

Click here for just this form. (fillable form)


  •  Complete all sections with the exception of the "Medical Clearance to Handle Animals" section.

 NEW!!!   New E-mail Address for Concentra Below!  NEW!!!

Submission Instructions:

  • Submit your completed form to Concentra by e-mail to Sara Jones at   (please do not use a photo from a cell phone).  INCLUDE NAME AND CELL NUMEBER ON E-MAIL.  Do not send encrypted files.
  • If you know you would like to receive vaccinations and other screening procedures available, please make an appointment at your nearest occupational medical clinic location from the choices listed at the bottom of FORM B. You must have the completed Form B with you when you attend your appointment to receive services.
  • Please contact the Josanne Hollingsworth-Maida with the EH&S Department at or 561-297-0778 with any questions regarding this process.