TO:
FROM:
Terry Blasdel, D.V.M.
Director, Animal Care Operations
SUBJECT:
Occupational Safety and Health Program for Animal Users
DATE:
30 July 2007
Participation in the Animal Care and Use Occupational Health and Safety Program is required
for personnel who are at risk because of contact with animals. This program has been approved
by the University of Houston, Clear Lake, Institutional Animal Care and Use Committee and by
Susan Prihoda, Director, UHCL Health and Disability Services.
All personnel who have any contact with laboratory animals are encouraged to participate in the
risk assessment of this program by answering the attached animal handler’s questionnaire Risk
assessment is accomplished through the use of the attached Health Surveillance Questionnaire.
On an annual basis you will be asked to update your information which you may do by
resubmitting the questionnaire or by answering that there has been no change. All information is
confidential and the questionnaires are kept at the Health Center on the UHCL campus. You
may refuse to answer the questionnaire, but you are encouraged to read it carefully to assess
your risks.
All university animal users, including students, are responsible for assuring that they are in
compliance with the program.
THIS FORM MUST BE RETURNED TO THE ANIMAL FACILITY OR TEACHER FOR DOCUMENTATION
THAT YOU HAVE BEEN INFORMED OF THE INHERENT RISKS OF RODENT EXPOSURE.
Last name:
First name:
Required of all personnel with rodent contact:
____
I will schedule an Animal Handler’s Physical exam and am submitting the Health Surveillance
Questionnaire to the UHCL Health Center, Susan Prihoda, SSCB 1.301, 281-283-2626.
____
I decline to have a physical examination but am submitting the Health Surveillance Questionnaire to the
UHCL Health Center.
____
I have read the Health Surveillance Questionnaire and decline to submit it to the UHCL Health Center.
____
I have filled out the Health Surveillance Questionnaire in the past and have reviewed it this year. I have
submitted that there have been no changes to the UHCL Health Center.
Optional but recommended:
____
I am going to the UHCL Health Center for a tuberculin skin test. I will submit the results to the UHCL
Health Center.
____
I am going to my physician for a tuberculin skin test. I will submit the results to the UHCL Health
Center.
Personnel and students with a history of allergies are strongly encouraged to fill out the questionnaire and talk
to Susan Prihoda about their medical history.
If you decline to submit the questionnaire, please initial that you have read the following statements.
____ I understand that rodents can cause allergies in humans.
____
I understand that the allergic reaction can be life threatening in individuals who are sensitive to other
allergens.
____
I understand that the use of proper personal protective equipment, such as a gown, mask and gloves,
will help protect me from exposure to rodent allergens and that these will be provided to me when I
handle rodents.
____
I understand that latex can also cause allergies. If I am allergic to latex, I will request nitrile gloves to
handle rodents.
____
I understand that rodents may bite and that a tetanus vaccination within the last 5-10 years is
recommended. Injuries from rodent bites should be reported to my supervisor or teacher.
Signed:
Date:
Revised 11.2009
Health Surveillance Questionnaire for Animal Contact and Use or Significant Biological Agents
UHCL Health and Disabilities Service Center
Houston, TX 77058-0300
281-283-2629
Confidential Medical Information
PURPOSE: The purpose of this form is to obtain individual health history for an employee working
with animals and other significant biological agents. It will be used to evaluate appropriate medical
surveillance needs.
CONFIDENTIALITY STATEMENT: This form requires that you provide personal health information that is protected by University
policy and State and Federal law. Your rights to the confidentiality of your personal health information will be strictly maintained by
Employee Health Services. Your information will be used or disclosed in accordance with those policies and laws only to the minimal
extent necessary for your treatment or business operations. You have the option of sending the form via regular mail or sending it via
interoffice mail to the address above.
INSTRUCTIONS: Please complete entire form. Answers left blank will be assumed to be a negative
response. The information you supply will be submitted to the UHCL Health Center medical staff for
review. If you have any questions on the form, please contact Susan Prihoda at UHCL Health Center
telephone 281-283-2629.
Last Name:________________________________ First Name: _______________________
SSN#_________________________________
Birth date: ________________________
Department:_______________________________ Job Title:__________________________
Have you had a previous animal handler questionnaire, medical surveillance, or vaccination at UHCL
Health Center?
No
Vaccines:
Yes
If yes, when
Please indicate what vaccines you have had. If you know the date, please provide.
Vaccine
Yes No
Date
Vaccine
Yes No
Date
Hepatitis B Series
□ □
__________
Rabies titer
□ □
__________
Hepatitis A Series
□ □
__________
MMR
□ □
__________
Measles
□ □
__________
Tetanus
□ □
__________
Rabies
□ □
__________
Oral Typhoid
□ □
__________
Vaccinia
□ □
__________
Qfever titer
□ □
__________
Tuberculosis Testing
Have you had a PPD (TB) Skin test?
Yes□
Date of last PPD skin test. ____________
No□
Result:
□ Positive □ Negative
If POSITIVE, date of last chest X-ray _________
If POSITIVE in the past, please indicate Yes/No for each of the following.
Yes
No
Yes
No
□
Fever
□ □
Chronic Cough
□
Bloody Sputum
□ □
Shortness of Breath
□ □
Weight loss
□ □
Have you had a Tuberculosis (BCG) vaccine? Yes □ No □
Date(s) you had a Tuberculosis (BCG) vaccine___________
Place of birth ___________________________________
Primary Language________________________________
Animal / Biological Agent Contact
Please indicate the animals you work with (Check the box if you work with the specified animal).
Amphibians
Birds
Cats
Cattle
Dogs
Ferrets
Fish
Gerbils
Goats
Guinea Pigs
Hamsters
Mice
Non-human Primates
Poultry
Rats
Rabbits
Reptiles
Sheep
Swine
Wild Rodents
Other (list):
Please indicate tissue, blood, or biological agents that you work with (check the box if you work with
the specified product).
Do you work with primate tissues? Yes□ No□
Do you work in an area where primates or primate tissues are housed or handled? Yes□
Do you work with human blood products? Yes□
Do you work with animal blood products? Yes□
No□
No□
No□
Do you work with human tissue? Yes □ No □
Do you work with animal tissue? Yes □ No □
Do you work with recombinant DNA technology? Yes □
No □
If yes, does the research involve techniques in which viable, recombinant DNA-containing microorganisms are used to infect animals that then require Bio-safety level 3 containment? Yes □ No □
Medical History
Have you had a prior history of the following conditions? Yes □
No □
If yes, please indicate the condition(s), and enter the date of onset (if known).
Condition
Yes
Pneumonia
□ _________
Recurrent Bronchitis
□ ________
Tuberculosis
□ _________
Heart Disease
□ ________
Rheumatic Fever
□ _________
Heart Murmur or Valve Disease □
Diabetes
□ _________
Kidney Disease
□ _________
Liver Disease
□ _________
Cancer
□ _________
Loss of Consciousness
□ _________
Arthritis
□ ________
Gastrointestional Disorders □
Seizures
Date
_________
□ _________
Chronic Back or Joint Pain □
_________
Condition
Yes
Date
_________
Have you been told by a physician that you have an immune compromising medical condition or are
you taking medications that impair your immune system (steroids, immunosuppressive drugs, or
chemotherapy)? Yes □ No □
Are you currently taking any medications (Including non-prescription)? Yes □ No □
If yes, list below: ________________________________________________________
For Women: Are you pregnant, or planning to be pregnant in the next year? Yes □ No □
Animal Related Injuries or Illnesses
Have you ever contracted a disease from animals, or experienced an animal related injury (including
bites, scratches, needle sticks, etc.)? If yes, please indicate the last 5 occurrences.
Date _____________ Injury/Illness _______________Treatment Location________________
Date _____________ Injury/Illness _______________Treatment Location________________
Date _____________ Injury/Illness _______________Treatment Location________________
Date _____________ Injury/Illness _______________Treatment Location________________
Date _____________ Injury/Illness _______________Treatment Location________________
Animal Allergies
Have you had any recent problems with the following symptoms? Yes □ No □
Please indicate which symptoms you have experienced (check the yes or no box next to each
symptom).
Condition
Watery or itching eyes
Runny nose
Sneezing
Wheezing
Chronic cough
Yes
No
Condition
Yes
Shortness of breath
Chest tightness
Rash or hives
Chronic allergies (dust, pollen, food, mold)
Asthma
Are these more frequent while at work? Yes □ No □
Are these symptoms associated with?
Dogs □
Pigs□
Cats □
Cattle □
Primates □
Rabbits □
Rats or Mice □
Guinea Pig □
Chemicals □
Latex □
Alfalfa □
Wood □
Horses □
Goats □
Bird (Feathers) □
Sheep (Wool) □
Weeds □
Trees □
Grasses □
Mold
Other □ List: ____________________________________________________________
No
Have these required any treatment with over-the counter medications (Claritin, Benadryl,
decongestants, eye drops, etc?) Yes □ No □
Have you had to wear a respirator, goggles or protective clothing to protect yourself from allergies
(e.g., hay fever [rhinitis], eye symptoms, hives or asthma) at work? Yes □ No □
Have you been treated by your own physician for allergies that began at work? Yes □ No □
Has you health status changed in the last year? □ No. □ Yes, please explain: ____________.
If you suspect you may have work related allergies or have any other questions about your health
status or this form, please contact:
Susan Prihoda
Director, Health and Disabilty Services
SSCB S1301
UHCL Health Center
Houston, TX 77058-0300
281-283-2629
Email contact: prihoda@uhcl.edu
ADDITIONAL INFORMATION: For detailed information on animal allergies and other hazards,
please request a copy of “Allergies in Animal Handlers” and “General Hazards Working with Lab
Animals” from Roberta Hohmann at 281-283-3015.
This information will now be evaluated and if further action is required, you will be contacted by
UHCL Health Center medical staff for additional information, action and training.