Pre-Medical Monitoring Referral Form Medical monitoring is voluntary and will be provided through Duke City Occupational Health. This will provide baseline testing that is a reference point for any future evaluations. This will be offered now and again in three (3) years. If you are interested in participating in the City’s medical monitoring program, please complete the following form and submit to the Risk Management Division of the City of Albuquerque. Fields with a red dot ⏺ are mandatory. Identification First Name Last Name Phone Number Use format xxx-xxx-xxxx. Your E-Mail Address Mailing Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code Employment Status Current Employee Yes No Department (Current) Job/Title (Current) Department (April 2022 through March 2023) Job/Title (April 2022 Through March 2023) Employee ID Former City Employee? Yes No Department (April 2022 Through March 2023) Job/Title (April 2022 Through March 2023) City Employee ID Employer (Current) Job/Title (Current) Non-City Employee? Yes No Employer (Current) Job/Title (Current) Employer (April 2022 Through March 2023) Job/Title (April 2022 Through March 2023) Presence at Gateway Center Were You Present at the Gibson Health Hub/Gateway Center Between April 2022 and March 2023? Yes No Please Provide All Dates You Were Present in the Gibson Health Hub/Gateway Center Between April 2022 and March 2023. On Those Dates, Where Were You in the Building? On Those Dates, How Long Were You There? On Those Dates, Why Were You in the Building? On Those Dates, What Were You Doing in the Building? Eligibility Acknowledgement Were You in the Construction Area or Adjacent Hallways of Phase 1 (Women's Shelter) on the Second Floor for Five(5) or More Days? Yes No Unknown Please Describe the Nature of Your Work or Activities in that Specific Area and How Often you Were There. If No I was not present in the construction area or adjacent hallways of Phase 1 at any time. I was present in the area, but for fewer than five (5) days. Approximate Number of Days Approximate Dates You Were There. Purpose of Your Visit(s). If Unknown, Please Describe. By Submitting This Form, I Affirm That the Information Provided is True and Accurate. Full Name Date Today's date. Captcha Submit Please confirm all required fields are populated before submitting your form. Fields with a red dot ⏺ are mandatory. Your form is not submitted until you click the Submit button and see the confirmation page which includes a recap of your completed form fields.
