Please consult your Supervisor for assistance with completion.  This questionnaire is designed to identify the following information:
(a)   Potential exposures, hazards, and risks associated with your position.
(b)   Information related to performing the tasks and functions of your position.

For questions or assistance, contact MSU Safety & Risk Management:  406-994-4146 or [email protected]

 denotes required fields.

General Information
Position Activities & Potential Hazards

Consult with your Supervisor for assistance completing these sections

**Please check all that apply**
Workplace Environment
Task Descriptions
Animal Care & Use
Biological Agents


Next Steps:

                     If you are in a Paid Position,
                        * If you answered 'YES' to either Animal Care & Use or Biological Agents,
                        * If you DID check any of the task specific questions related to your                                        position
     After Safety & Risk Mgmt. receipt and review, please watch your email for instructions and completion of Part II - Occupational Medical Surveillance Form.

                     If you are in anUnpaid Position, and/or
                        * If you answered 'NO'to both Animal Care & Use and Biological Agents,                              and/or
                        * If you DID NOTcheck any of the task specific questions related to your                              position
     Please note the absence of these risk factors indicate you do not qualify for the MSU Occupational Medical Surveillance Program.  If needed, you may seek medical consultation with this form through your own provider - for example, students may consult with University Health Partners.

If your position, hazards, or health status changes at any time, please contact Safety & Risk Mgmt. for assistance:  406-994-4146 or [email protected]