UTHealth Houston Occupational Health Program Enrollment

UT Health Services (UTHS) is the medical provider for the Occupational Health and Safety Program for UTHealth Houston. UTHealth Houston has indicated that you are in a job which requires enrollment in the Occupational Health Program; completion of this form ensures your enrollment in the Program. Please complete the form as able in its entirety - the information requested allows UTHS to assess potential risks to your health and to provide appropriate care. Completion of the form is required prior to any scheduled appointment with UTHS if necessary. You will be asked to upload proof of any immunizations at the end of this form.

Last Name, First Name

Date of Birth

MM/DD/YYYY

Gender

Female

Male

Decline to answer

Phone Number

Phone

Your preferred email address to be contacted if necessary

Supervisor, Sponsoring Agency, or Faculty Sponsor

Department

Job Title or Visiting Scholars Category

Role Status

Estimated Length of Stay

If student or visitor (3 months, 6months, etc.)

Will you be working with animals/animal tissue/biological agents?

Please indicate if you have had recent problems with the following allergy symptoms

If "none" please indicate below

Past Medical History and Review of Symptoms

Have you had any of the following?

If "none" please indicate below

Current Vaccination Review

After submission of occupational health enrollment form, employee health will review for any immunizations, testing, or surveillance you may need. If any testing or immunizations required are lacking, you will be notified by phone or email before clearance can be given.

If you have vaccine records you would like to submit you may submit them here. If you were recently onboarded as a new employee, employee health will take into account services already provided by employee health.

File Upload

Drop your files here

CONFIDENTIALITY STATEMENT: Confidentiality Statement, Acknowledgement and Consent to store your Health and Immunization Data (as a UTHealth Houston Employee, student, or visitor) in Smartsheet, a HIPAA compliant protected record system utilized by UT Health Services.

1. I understand that my health information which is required for employment or course enrollment will be stored within Smartsheet, one of the health record systems for UTHS. If additional care is needed my health information may be stored within EPIC, the electronic health record system for UTHS and UT Physicians.

2. As an employee, student or visitor of UTHealth Houston, my health Information will be stored with security measures in place, limiting who may access the stored health data. My employee health data will be stored Smart sheet which is only accessible by UTHS personnel. New vaccinations, blood titers and allergy status may be stored in EPIC if these services are required for my health and safety.

3. I understand that certain information related to my employment or course enrollment (such as vaccination status) may be disclosed for internal use for the administration of the animal care operations of UTHealth Houston.

a. If I receive a Flu, Covid, Hepatitis or other communicable disease vaccine through employee health I understand it will be stored in Epic.

4. If I have not provided proof of my vaccination(s), I give UTHS permission to verify my vaccination status via ImmTrac2, the state immunization registry.

5. I understand that I can schedule a vaccine appointment and request my vaccine records from UTHS.

6. I also understand that information concerning my vaccination status may be disclosed for reporting to local, state and federal public health agencies, including but not limited to the Food and Drug Administration (FDA), Centers for Disease Control (CDC), Texas Health and Human Services Commission (HHSC), and Immtrac2, the state immunization registry, as required by law.

7. The health information that I have disclosed will be stored separately from my personnel or student file.

HIPPAA Privacy Notice

https://www.uth.edu/legal/privacy-practices.htm

By clicking "I do hereby authorize” below, I give my consent to store my personal health and immunization data within Smartsheet and Epic (both HIPAA compliant) and agree to the terms above for occupational health enrollment. If you choose to decline please contact UT Health Services directly.

I understand that I may revoke this authorization in writing at any time except to the extent that UTHS has already relied on this authorization. I understand that I may revoke this authorization by mailing or emailing a written notice to 6410 Fannin, Suite 100 Houston, Texas 77030, occupational.health@uth.tmc.edu

Do you hereby authorize or decline UTHealth Services - Employee Health to put your information into Epic Health Record if needed?

Employee health has now transitioned to use EPIC and Smartsheet for employee health. This will allow you to: have direct access to immunization records, labs, and ease of use for future appointments and scheduling done by employee health. Employee health cannot see your personal health diagnoses or doctor visits as we utilize a different service area not used by general health clinics.

I do hereby AUTHORIZE UTHS to store my health information into Smartsheet or Epic and AUTHORIZE Occupational Health Program Enrollment.

I do hereby DECLINE UTHS to store my health information into Smartsheet or Epic and DECLINE Occupational health program enrollment.

E-Signature

Today's Date

MM/DD/YYYY

If you suspect you may have work related allergies or have any other questions about your health status or this form, please contact UTHS at 713-500-3267.

https://www.uthealthservices.com/

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