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Community Care Physicians

OCCUPATIONAL HEALTH SERVICES 
Rennselaer Technology Park, 101 Jordan Rd., North Greenbush, NY  12180 
(518) 274-9126
Fax (518) 274-9487

Annual Health History
Research Animal Users

If you are associated with the University at Albany and have a NetID, you may log in via the link at the top of this page and submit this form electronically. Your name and email address will then be filled in automatically. If you do not have a NetID, you will need to fill this form out and then print and fax it to the number at the top of the form.

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6. Have you had any of the following symptoms, not associated with a cold or flu, in the last 5 years?

I have read and understand the attached HIPAA form and authorize Community Care Physicians, P.C. to use and/or disclose certain protected health information (PHI) about me to the Research Compliance Officer, Adrienne D. Bonilla, and my Principal Investigator.

Disclaimer

I understand that by submitting this form, the information entered into this form will be transmitted via email over the Internet which may not be secure. If this is unacceptable to me, I can instead print out the form and fax it to the number at the top of the form.

 



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