University ofNorth Texas
MEDICALHISTORYQUESTIONNAIREFORINVESTIGATORS,TECHNICIANS, STUDENTS,OTHERSEXPOSEDTOLABORATORY ANIMALS
Individual’s Name:
Principal Investigator’s Name:
UNT Department:
Date Questionnaire Completed:
UNT MEDICAL HISTORY QUESTIONNAIRE FOR
INVESTIGATORS, TECHNICIANS, STUDENTS & OTHERS EXPOSED TO LABORATORY ANIMALS
Completion of this questionnaireisan annual requirementfor workingwithlaboratoryanimals or animaltissuesorhavingaccessto any animal laboratory on campus.
COMPLETE ALL INFORMATION-INCOMPLETE FORMS WILL NOT BE ACCEPTED
Identification
Last NameFirst NameMiddle
Date of Birth______(MM/DD/YY)Gender______(M/F)
IACUC Protocol Number(s) ______
Principal Investigator: Department:
Principal Investigator’s Phone Number: ______
Contact Information
Campus AddressPermanentAddress
Bldg/Room
ExtensionCity Zip
E-mailPhone
In Case of EmergencyPersonal Physician
Notify
RelationshipFacility
PhoneCity
Date of most recent physical exam (MM/DD/YY)
Current Status(check all that apply):
Student: Faculty Undergraduate Graduate
Staff Other
Exposure Level (see description of Levels below)Species / Level of Exposure
I / II / III / IV / I / II / III / IV
Birds/Poultry / Other ______
Rodents / Other ______
Rabbits
Fish
Frogs
Gerbils
Hamsters
Other ______
Level I / No direct contact but enters animal laboratories.
Level II / Does not conduct procedureson live animalsbut handles “unfixed” animaltissues andfluids.
Level III / Minor exposure (handles,restrains,collectionofspecimensoradministerssubstancetoliveanimals).
Level IV / Majorexposure (performsinvasive proceduressuchassurgeryor necropsy).
CAUTION: Some infectiousdiseases, including certain zoonoses,areknowntoadversely affect fetuses. If you or someone inyourhousehold is pregnantor planning to become pregnantsoon,please discussyour risk level withahealthcareprofessional at the UNT Student Health and Wellness Center or yourpersonal healthcare providerpriorto working withanimals or animal tissues.
Riskof Injury (CheckOne)
Low RiskFish or amphibians
MildRisk Rats, mice, rabbits,guineapigs, hamsters, gerbils,and birds with risk of injury
(primarily bites and scratches), zoonotic diseases,and significant potential for allergies.
Moderate RiskWild rodents withmoderate risk of injury (primarily bites and scratches),zoonotic diseases(rabies,Q Fever,hantavirus, Bacterial and fungal infections) and significant potential for allergies.
Section A: Medical History
1. Are you allergic tolatex,animal feed, or substances/chemicals used for work withlive animals or animal tissues? / Yes ______/ No ______Material/Substance/ Chemical / Reaction(s) / Frequency / Severity
2. Doyou have anyhealthconditions that are pertinent toyourwork with animals or animal tissues, suchasimmunesuppression,pregnancy orattemptingpregnancy,heartvalvedisease, splenectomy,chronicliver or kidney disease,diabetes,malignancy,chronicback pain, asthma, seizures, or HIV infection? If “yes” or “possibly yes,” describe below. / Yes _____ or
Possibly _____
Yes / No ____
3.Insert thedate of your most recentvaccination for tetanus(check withyourhealthcareproviderif you areunsureofthe date). If youhavenothada tetanusvaccination or cannot verify the date, markthe appropriate column.
Immunizations / Month/Day/Year / NoVaccination / CannotVerify
(Tetanus(booster)
4. Have you ever contracted a serious illness fromananimal or hadananimal inflict a seriousinjury? / Yes _____ or
Possibly _____
Yes / No ____
5. Haveyoueverhad anyproblems (suchas allergy symptoms, shortness of breath, coughing, wheezing orskin problems)as a result of exposureto animals? / Yes _____ or
Possibly _____
Yes / No ____
List Animal Species / Reaction(s) / Frequency / Severity
6. Will you be working withhuman blood,body fluids or tissue?
Yes No If “yes”, please describe: ______
Training
Ihavecompletedthe required CITI basic Working with the IACUC trainingcourse and the species-specific training courses for the species I will be working with. Yes No
Section B. Signatureof Employee or Student
Please readthe following,signand date beforesubmitting.
The aboveinformationis trueand complete tothe best ofmy knowledge and Iamawarethat misstatements or omissions may jeopardize my health.
Signature of Employee or StudentDate
SectionC:Authorization forReleaseofRecommendations to Principal Investigator
I authorize the UNT Student Health and Wellness Center to release anyrecommendations fromits reviewing physician to the Principal Investigator for the animal research projects that I will be working on. I understand that any such recommendations will not include any information regarding my health history or diagnoses but will be limited to communicating restrictions, inoculations needed, or other recommendations regarding my contact with live animals or animal tissues at UNT.
Signature of Employee or StudentDate
SectionD: SignatureofEmployeeor Student Declining Participation in the Program
If you havedecided not to complete this questionnaire and not to participate inthis aspect of theprogram, please date and sign this block. Thiswill havenoeffecton your employment. However, it may affectyour access to facilities where laboratory animals or animal tissues are housed. Atany time that you decideto participate inthe OccupationalHealth andSafety Programyou may doso.
Medical History QuestionnaireWaiver
Ideclineparticipationinthe Medical History Questionnaire review process for animal workers at this time.
Iunderstandtheoccupational risks ofworking with animals and animal tissues.
Signature of Employee or StudentDate
Enclose thisquestionnaire ina sealedenvelopewithyour name and your Principal Investigator’sname ontheoutside. Send/bring tothe IACUCstaff in the Office of Research Integrity & Compliance,Hurley Administration Building Room 121H. The sealed envelope containing the questionnaire will behand-delivered by the IACUC staff to the UNT Student Health and Wellness Center for review by one of its physicians.
ForUNT Student Health and Wellness Center Use Only
Reviewed byDate
Comments ______
______
Recommended Precautions Communicated to Principal Investigator (on Date______)
______
______
______
______