University of Arkansas
Animal Worker Health Screening Questionnaire
In order to comply with the University of Arkansas’ Assurance of Compliance with the US Public Health Service (PHS), Office of Laboratory Animal Welfare, all individuals who engage in research activities, supported by PHS, using live vertebrate animals, or conduct animal research in PHS covered facilitiesmust participate in a safety and health protection program prior to beginning work with animals. All animal workers must be informed of known health and safety risks, trained in safety protections or practices, and provided with appropriate Personal Protective Equipment (PPE) other than routine laboratory coats/smocks/jackets. Health screening is required when the animal work presents more than minimal risk of allergy/asthma, development/exacerbation of or contracting zoonotic disease (disease capable of being transmitted from animal to human). Individuals for whom health screening is required include those who are involved in the direct care of, or have direct contact with, laboratory rodents or birds that are procured from authorized breeding sources/vendors and wild mammals and birds, whether captured and released in the field or maintained in an animal facility. Faculty, staff and students must complete this screening questionnaire which will be reviewed by a licensed, health care provider from the Pat Walker Health Center (PWHC). Individuals who have a medical history raising concerns with working with animals will be referred to their primary care provider or the Arkansas Occupational Health Clinic located in Springdale; phone number (479) 725-3000.
Instructions:Complete this form and submit it directly to the PWHC, ATTN: AJ Olsen either by fax at (479) 575-8793 or email to . Once reviewed by a PWHC medical provider, he/she will send you and the IACUC coordinator () email confirmation.
THIS FORM CONTAINS CONFIDENTIAL MEDICAL INFORMATION FOR HEALTH CARE PROVIDER USE ONLY.
Animal Worker Name: / University ID No.University Email Address: / Date of Birth:
Supervisor’s Name: / Department:
Department Cost Center No. (if applicable for payment):
Full-Time Employee Part-Time Employee Grad Student Undergrad Student Visiting Faculty/Staff
ROLE HISTORY/PROPOSED ROLE:
Indicate the type(s) of animals you do or will handle through your work at UA (check all that apply):
Rats Mice Hamsters Chickens Rabbits Other
Yes No Did you receive instruction regarding species-specific risks and handling information from your
Supervisor?
Yes No Do you work outside of UA with non-human primates, with primate tissues, or in an area where
primates or primate tissues are housed and handled?
Yes No Do or will you work with other feral (wild) animals or random source (Class B) dogs or cats?
Yes No Do or will you work with human blood products or human tissue?
MEDICAL HISTORY:
Have you had any of the following (check all that apply)?
Pneumonia in the last year Recurrent Bronchitis or asthma Heart Disease
Heart Murmur/Heart Valve Disease Diabetes Kidney Disease
Liver Disease Gastrointestinal Disorder Cancer
Seizures/Epilepsy Immune system deficiency Chronic Lung Condition
Animal Worker Name: / University ID No.
MEDICAL HISTORY (Continued):
Yes No Have you ever contracted a disease from animals or experienced any animal related injury (including
bites, scratches, needle sticks, etc.)? If yes, please explain:
Yes No Have you been told by a physician that you have an immune compromising medical condition or are
you taking medications that may impair your immune system (steroids, immunosuppressive drugs, or
chemotherapy)? If yes, please explain:
Yes No Are you currently taking any medications? If yes, list:
Yes No For women: Are you pregnant or planning to become pregnant in the next two years?
ALLERGY HISTORY:
List any allergiesto medications:
Do you have any of the following (check all that apply)?
Chronic cough Asthma Hay fever Skin rash Itchy, irritated eyes
Are you allergic to any of the following (check all that apply)?
Dog Cat Cattle Horse Bird/Feathers
Hog Primates Rabbit Goat Sheep/Wool
Rat or Mouse Guinea Pig Alfalfa Weeds Trees
Grasses Wood Chemicals Latex Insect Stings/Bites
Animals at your work site Other: ______
Animal Worker Name: / University ID No.
IMMUNIZATIONS:
Indicate status of vaccination or blood test to document immunity (check only one for each immunization/immunity check):
Measles Had – Date: ______ Had but do not recall date Have not had Unsure
Mumps Had – Date: ______ Had but do not recall date Have not had Unsure
Rubella Had – Date: ______ Had but do not recall date Have not had Unsure
Hepatitis A Had – Date: ______ Had but do not recall date Have not had Unsure
Hepatitis B Had – Date: ______ Had but do not recall date Have not had Unsure
Rabies Had – Date: ______ Had but do not recall date Have not had Unsure
CMV Had – Date: ______ Had but do not recall date Have not had Unsure
Toxoplasmosis Had – Date: ______ Had but do not recall date Have not had Unsure
“Q” Fever Had – Date: ______ Had but do not recall date Have not had Unsure
Yellow Fever Had – Date: ______ Had but do not recall date Have not had Unsure
Smallpox Had – Date: ______ Had but do not recall date Have not had Unsure
Tuberculosis (BCG) Had – Date: ______ Had but do not recall date Have not had Unsure
Date of last Tetanus booster: ______
Date of last PPD (tuberculin) skin test or T-Spot blood test: ______ Negative Positive
If TB test positive, date of last chest x-ray: ______
If TB test positive in the past, are you having any of the following symptoms (check all that apply)?
Fever Chronic cough Bloody sputum Weight loss Shortness of breath
This section to be read and signed by the ANIMAL WORKER
My signature indicates that the above information is true and accurate to the best of my knowledge.
______
Animal Worker Signature Printed Name Date
This Certification page should be completed by the health care provider and returned to RosemaryRuff, Director of Research Compliance; 205 Administration or by FAX (479) 575-3846 or email .
Animal Worker Name: / University ID No:ANIMAL WORKER HEALTH SCREENING CERTIFICATION
The above-named individual received a health screening by review of this Animal Worker Health Screening Questionnaire on (date) ______.
He/she has been immunized against Tetanus within the last ten (10) years and will remain current for at least the next
twelve (12) months.
He/she has been additionally immunized for the purpose of work with animals against (specify):
______.
If this individual has been determined to be at more than minimal risk of health consequences of working with animals, he/she has been counseled and advised by a physician regarding those risks.
If applicable, this individual has been advised of the need for additional visit(s).
This individual must wear removable laboratory coats/jackets/smocks while working in animal facilities and laboratories. Special PPE required for this individual includes:
______
Health Care Provider SignatureDate
Printed Name: ______
Title: ______
Address: 525 N. Garland Ave., Fayetteville, AR 72701
Telephone:(479) 575-4451
Please return this Health Screening Certification form (one page only) to:
Tina Poseno, IACUC Coordinator
42 AFLS or email