CENTER FOR HEALTH INFORMATION REQUEST FORM

Privacy Statement

(CONFIDENTIAL)
The Center for Health Information (CHI) is a collaborative project sponsored by the Scientific Library and Occupational Health Services. The Scientific Library protects the privacy of its users. In accordance with its policy on confidentiality, the Library will not reveal transactions indicating the use of specific resources by its individual users. Records pertaining to the use of the Library and its resources and subjects of inquiry are confidential, and shall not be disclosed either to other users, to members of the staff who are not authorized, or to other inquirers.

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Required Fields

	Your Name:	Phone Extension:
Bldg:	Room Number:
	Email:	Other Address:
	I request that the Scientific Library provide me with information on the following health-related subjects. I realize that the Library accepts no responsibility for the outcome of my interpretation and use of any information provided, and and that any use I make of it is my responsibility.	Were you referred to the Library for assistance? Yes:No:
	If referred Person's Name :
	What type of information are you looking for? Please provide as much information as you can. It is helpful to have as complete a description as possible. Where possible, please use the same terminology as that a health care provider or professional would use. Occupational Health Services personnel would be happy to assist you in describing your information need, and to discuss the results of your search with you.
	If referred Person's Name What types of information would you like: (to select more than one choice hold down control:	Journal Books Government Reports Pamphlet/Brochure WWW Pages
	Please choose one delivery option:	Mail E-Mail Call and hold at Circulation Desk

If you want to print out a copy of this form for your records press "Print page"