The Occupational Health Monitoring Program Health History Form

Purpose of this Form

This Health History Form must be completed and submitted to Great Lakes Physician Services (GLPS), Erie County Medical Center, in order to enroll in UB’s Occupational Health Monitoring Program. If required, GLPS will contact you to schedule an appointment for a health assessment. This form is kept confidential by GLPS according to HIPAA guidelines.

Personnel must re-enroll in the Occupational Health Monitoring Program annually.

Form Facts

Form Type: PDF

Updated: 07/14/2021

Owner: IACUC

Form Instructions

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