Welcome to Medical Health Questionnaire Online

Take the Animal Questionnaire

UCLA provides an occupational health and safety program that is consistent with federal, state and local regulations. All personnel involved in the care and use of research animals, including those in DLAM, investigator staff/students, personnel that handle animal tissues, and all PIs and faculty sponsors of Animal Research Committee (ARC) protocols (regardless of whether they handle animals), must be enrolled in the program. UCLA Policy 990, “Use of Animals in Research, Teaching, and Testing,” describes the requirement for annual submission of the Medical History Questionnaire (MHQ) for review by Occupational Health Facility(OHF) personnel.

The MHQ assists the OHF personnel to identify general lab animal or animal facility related hazards in the context of an individual’s exposure risks. It is possible we will require additional medical information for your MHQ application. As such, please allow a minimum of 30 days from application submission to approval.

Take the Respiratory Questionnaire

California Occupational Safety and Health Administration (Cal/OSHA) and the UCLA EH&S Respiratory Protection Program requires that all users of respiratory protection complete the following annual medical evaluation questionnaire.

The medical health information in this questionnaire is confidential under the Health Insurance Portability & Protection Act (HIPAA). Only UCLA Occupational Health (OH) medical practitioners will review the medical portion of this questionnaire for faculty & staff. Student submissions will be reviewed by providers from The Ashe Center. EH&S will be notified of the medical evaluation status (i.e. pass or fail), along with users contact information. Please provide honest and complete answers to these questions.

Occupational Health or the Ashe Center will contact you directly to request additional information or for any follow-up medical care, including medical testing to evaluate your ability to wear a respirator. Occupational Health can be reached at (310)825-6771, and located at 10833 Le Conte Avenue, Suite 17-240 CHS, Los Angeles, CA 90095-1725. Contact EH&S at (310) 825-5689 with any questions about the respiratory protection process.

Student Questions: please e-mail asheimmune@ashe.ucla.edu || Faculty & Staff Questions: please e-mail MHQOHFQuestions@mednet.ucla.edu || Technical Questions: please e-mail: mhqsupport@mednet.ucla.edu