ࡱ>  %bjbj \xxE77777KKK84lK.##(KKKhhhqssssss$ "7h(@hhh77KKhd7K7KqhqKpMx7K]0,l#f@l#l#7@hhhhhhhhhhhhhhl#hhhhhhhhh : Animal Contact Health Surveillance Questionnaire This confidential medical history form must be completed on initial enrollment and annually thereafter as a requirement for working with research animals. The information provided in this questionnaire will be reviewed by the Wellness and Counseling Center and maintained by the Wellness and Counseling Center. Please answer all questions completely: contact your projects Principle Investigator (PI) if unsure of answers. Part I-Section A-B are to be completed by Supervisor/Principle Investigator (PI); Supervisors/PI needs to complete this form one time for individuals under their supervision. A faculty PI should complete this form for him/herself. Part II-Section A-D are confidential and are to be completed by employee. All information must be completed and returned to the Wellness and Counseling Center. Part I: Animal Contact Review Questionnaire Section A: Participant InformationParticipant Name:M ( F ( DOB:Faculty/Student ID Number:Job Title:Phone#:E-Mail:Dept and work address:PI:Protocol #:Position: Faculty ( Staff ( Student ( Other ( _________________________________ (Check all that apply)  Section B: Must be completed by supervisor of participant Species Level of ExposureSpeciesLevel of ExposureIIIIIIIVIIIIIIIVAmphibian((((Rat((((Birds/Poultry((((Other((((Ferrets((((((((Guinea Pig((((((((Mice((((((((Rabbits((((((((Level I No direct contact but enters animal facility. Level II Does not conduct procedures on live animals but handles unfixed animal tissues and fluids Level III Minor exposures (handles, restrains, collection of specimens or administers substance to live animals) Level IV Major exposures (performs invasive procedures such as surgery, necropsy.) For Live, animals under section B indicate any work with the following Recombinant DNA..( NO ( Yes Infectious Agents.( NO ( Yes ( specific agent:___________________ Bloodborne Pathogens.( NO ( Yes Human Cell Lines( NO ( Yes Extremely Hazardous Agents..( NO ( Yes( specific agent: ___________________ Radiation/Radioisotopes..( NO ( Yes( specific agent: ___________________ Lasers (class3b, 4a)..... ( NO ( Yes( specific agent:___________________ Toxins..( NO ( Yes( specific agent: ___________________ By Signature, I certify that the information provided is accurate. Printed Supervisor/PI Name_____________________________ Signature: ________________________________________ Date: _____________________ Part II: Initial Health Surveillance Questionnaire Information in this part is confidential and should be completed by employee only. You are being asked to complete this questionnaire to help us evaluate risks to your health from exposure to animals while at work. Section A: Participant InformationEmployee Name:M ( F ( DOB:Faculty/Student ID Number:Job Title:Phone#:E-Mail:Dept and work address:PI:Protocol #:Position: Faculty ( Staff ( Student ( Other ( _________________________________ (Check all that apply)  Section B: Medical HistoryHave you ever had any of the following immunizations? Tetanus: Yes ( No( Dont know ( Year of most recent __________ Personal Health HistoryYesNO1.Have you ever contracted an illness from animals, or experienced and animal related injury?(( If yes, explain 2. Have you been told by a physician that you have an immune compromising medical condition or are taking medication that impair your immune system ( steroids, immunosuppressive drugs, or chemotherapy)(( If yes, explain 3. Are you currently taking prescription and/or over the counter medication?(( If yes, please list 4. Do you have any know valvular disease (heart murmur) or congenital heart disease(( If yes, please list Please Note: Animals or specific agents can be a risk during pregnancy. Consult your physician prior to working with animals or specific agents if you are pregnant or intend to become pregnant. Environmental Allergies/AsthmaYesNO1. Are you allergic to animals(( If yes, list animals2.Do you have any other known allergies? (e.g. Latex, animal feed, substance or chemical use)((3. list symptoms that occur when you are suffering from your allergies:  Severity of symptoms: ( Mild ( Moderate ( Severe ( NA5. Do you have asthma?(( If yes, list cause(s) of asthma (if you dont know write unknown): 6. Do you have allergy symptoms or asthma specifically related to animals?(( If yes, list symptoms  Severity of symptoms: ( Mild ( Moderate ( Severe ( NA  Environmental Allergies/AsthmaYesNO 7.Do you experience shortness of breath?(( If yes, explain Additional personal health concernsDo you have any health or workplace concerns not covered by the questionnaire that you feel may affect your occupational health and would like to confidentially discuss with the Wellness Center or your personal care physician?(( If yes. Explain:  Section C: Signature of participant in program (complete section A,B,C) The Above information is true and complete to the best of my knowledge and I am aware that deliberate misrepresentation may jeopardize my health. I understand that this information is confidential and will not be released without my knowledge and written permission. _________________________ Print Name of Participant _________________________ ___________________________ Signature of Participant Date     Created by H.Acosta Page  PAGE 1  DATE 5/21/2012 123   3 4 J h j . 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