Medical History Questionnaire (MHQ)

  • In accordance with University Policy, annual completion of this form is mandatory for all personnel having contact with research animals or animal tissues and all personnel who have a security key card or key to enter the vivarium. Forms can be submitted online (see Related Information to download the form).

Medical History Questionnaire Waiver Form for Visitors

  • In lieu of submitting the Medical History Questionnaire (MHQ) form, visitors may complete the MHQ Waiver Form provided they: 1) are not UCLA faculty, staff or students and 2) will only have transient contact with animals or animal or human tissue for a period of time not to exceed 3 days. All others must complete the MHQ.
  • The MHW Waiver Form is not available for completion online.
  • Please return the completed form to: Occupational Health Facility, Ext 56771 by:
    • FAX: (310) 206-4585 or on-campus mail: 67-120 CHS, Mail Code: 172518
    • For off-campus mail: UCLA Occupational Health Facility BOX 951725, 10833 Le Conte Avenue., 67-120 CHS Los Angeles, CA 90095-1725