Academic Year:
The University of Mississippi
Occupational Health Evaluation
QUESTION: Who sees my personal medical information?
ANSWER: If you put this form in a sealed envelope, it is treated with all the safeguards as any other medical record. Only the Occupational Health Physician in the UM Employee Health Program reviews this information.
Instructions: Fill out the personal information below.Complete Part I and, unless you decline to do so, Part II. If you decline, please make sure to check the box &sign that you decline. Deliver in a sealed envelope toDr. Harry Fyke, University of Mississippi, NCNPR B104, University, MS 38677.
PART I(to be completed by the employee with assistance from the Director/Supervisor/Principal Investigator if needed)
Name / Last: / First: / MI:
Today’s Date / UM Personnel #
Gender Female Male / Date of Birth
Date of last tetanus vaccination: / / UNKNOWN ~ Call IACUC Office (x5006)
for assistance in obtaining a vaccination.
Campus Address / Phone
Home Address / Phone
Department/Unit / Phone
Position Title
Supervisor / Phone
Personal Physician’s Name / Phone
Physician’s Address
PURPOSE: Certain drugs and medical conditions may place you at increased health risk in certain work environments that involve animal research. Such drugs and conditions include but are not limited to steroids, allergies, cancer, chronic diseases, pregnancy, surgical procedures, and absence of spleen, stress, and deficiencies of the immune system. This information is requested to benefit you and the Occupational Health physician, who reviews this form to recognize the health risks posed to you by animal research and to recommend ways to reduce those risks.
Personal medical information used to assess occupational risk is requested on the following page.
I agree to provide this information.
Signature:Date:
I have read and understand the above section entitled ‘Purpose’ and I understand
the confidentiality safeguards, but I declineto provide the information requested.
Signature:Date:
PART II(to be completed by the employee with assistance from the Director/Supervisor/Principal Investigator if needed)
Check the appropriate response for each item below.
1.Do you have any allergies?
Drugs: / Type of Reaction:
Hives / Rash / Difficulty Breathing / Anaphylaxis
PenicillinY N / Y N / Y N / Y N / Y N
SulfaY N / Y N / Y N / Y N / Y N
ASAY N / Y N / Y N / Y N / Y N
CodeineY N / Y N / Y N / Y N / Y N
DemerolY N / Y N / Y N / Y N / Y N
ErythromycinY N / Y N / Y N / Y N / Y N
Other: / Y N / Y N / Y N / Y N
Environmental: / Type of Reaction:
Hives / Rash / Difficulty Breathing / Anaphylaxis
PollenY N / Y N / Y N / Y N / Y N
House DustY N / Y N / Y N / Y N / Y N
MoldY N / Y N / Y N / Y N / Y N
Stinging InsectsY N / Y N / Y N / Y N / Y N
Animal DanderY N / Y N / Y N / Y N / Y N
LatexY N / Y N / Y N / Y N / Y N
FoodY N / Y N / Y N / Y N / Y N
FeathersY N / Y N / Y N / Y N / Y N
Other: / Y N / Y N / Y N / Y N
2.Do you have a chronic medical illness?
High Blood PressureY N / AnginaY N / Heart DiseaseY N
Colon ProblemsY N / EmphysemaY N / Allergic RhinitisY N
CirrhosisY N / TBY N / DiabetesY N
Irritable Bowel SyndromeY N / AsthmaY N / Thyroid ProblemsY N
Hearing Problems/Ear InjuryY N / COPDY N / Other:
3.Have you ever had surgery?
AppendectomyY N / Gall BladderY N / TonsillectomyY N
Hernia RepairY N / HysterectomyY N / Other:
4.Do you take daily medications?
A. Medication / Amount / Dosage
B. Allergy Shots / Amount / Dosage
5.Do you have problems with your immune system?
Corticosteroid TherapyY N / ChemotherapyY N
SplenectomyY N / Other:
6.Are you pregnant? Y N NA
7.Are you planning to conceive within the next 12 months? Y N NA
IACUC Occ Health Eval Form [Jun 07]page 1