Work Environment Allergy Checklist

Full Name *

Date of Birth *

Position/Job Title

Date of Submission *

Do you have any known allergies? *

If you selected 'Other', please specify

Describe any reactions or symptoms you experience from these allergens

Do you require any special accommodations to minimize exposure to allergens?

If yes, please describe the accommodations needed

Do you carry any emergency medication (e.g., EpiPen, antihistamines)? *

If yes, please specify which emergency medication you carry

Additional comments or concerns related to workplace allergens

Signature of Employee *