Medical Survey Questionnaire Login

The medical survey form can only be accessed by entering a valid Virginia Tech PID and password. If you previously logged-in using a non-Virginia Tech PID, please contact safety@vt.edu or call 231-5985 for assistance and do not login until you have contacted EHS.

If you do not have a valid Virginia Tech PID, you will need to obtain one by completing the form found here. If you have a PID and have forgotten your password, go here.

This form should take about 15-30 minutes to fill out and consists of five pages. We suggest having your medical records on hand as some of the questions concern your medical history. The information on each page is checked for errors and omissions and saved when you click the "Save and Continue to Next Page" button. Your form is not completed until you click the "Save and Submit" button on page 5. You may quit the form (close browser window) at any time; however, any changes made to the current page will be lost. You may return to the form and add or change data at any time, but you must "Save and Submit" the form for changes to be completed. The form will automatically log you out after 15 minutes if no changes are made. If you need assistance, call 231-4034.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. 'Genetic information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

NOTE: If you are a minor, EHS will not collect a medical history. Rather, we will contact you to request your parent(s) or other legal guardian provide us written authorization to collect such information. EHS cannot provide medical services for minors until such an authorization has been received. If you have questions related to this matter, please call 231-5985.