Drexel University
Institutional Animal Care and Use Committee
Annual Health Review
Your Name:__________________________________ Drexel University ID No:_________________________
Your Academic Program or Department:___________________________
Your work (school) telephone number:_____________________________
In order to help assure that no health problems arise as a result of your work with animals, please respond to the
following questions.
1. For the past year, please check all the categories you matched.
ULAR animal and veterinary care staff
Non-ULAR person with direct contact with monkeys
Non-ULAR person with direct and frequent contact with rodents and rabbits
Non-ULAR person with direct contact with sheep or goats
Non-ULAR person with direct but infrequent contact with animals
I worked directly with recombinant DNA, pathogenic organisms, chemical carcinogens or
Yes
cytotoxic drugs. If “yes”, please circle the potential hazard.
No
2. For the coming year, please check all the job categories you think you will match.
ULAR animal and veterinary care staff
Non-ULAR person with direct contact with monkeys
Non-ULAR person with direct and frequent contact with rodents and rabbits
Non-ULAR person with direct contact with sheep or goats
Non-ULAR person with direct but infrequent contact with animals
I will work directly with recombinant DNA, pathogenic organisms, chemical carcinogens or
Yes
No
cytotoxic drugs. If “yes”, please circle the potential hazard.
Yes
No
3. Do you have a history of asthma?
No
Do you have a history of eczema (allergic skin conditions)?
Yes
No
Do you have a history of allergic rhinitis (sneezing, runny nose, etc.)?
Yes
No
Do you have a history of a medical problem that may be work related?
Yes
If yes, what is that problem(s)_________________________________________________________
_________________________________________________________________________________
No
4. Do you have any illness which compromises your immune system?
Yes
No
Are you taking any medicine which may compromise your immune system?
Yes
If yes, list those medications__________________________________________________________
_
________________________________________________________________________________
No
In the past year, did you develop any new medical problems?
Yes
If yes, list those problems____________________________________________________________
_________________________________________________________________________________
No
If yes, do you think any are related to your work?
Yes
Which one(s) may be related to our work?_______________________________________________
I authorize Drexel University and Drexel University College of Medicine to conduct a medical examination to
determine whether I can work with laboratory animals. The Institutional Animal Care and Use Committee and
Supervisor/Principal Investigator may be informed only of the date of medical evaluation to verify my participation
in the Occupational Health and Safety Program, and whether or not may continue to work with laboratory animals
(or any restrictions in doing so).
Date: ______________________________
Signature: ________________________________
Occupational Health History
Drexel University/ Drexel University College of Medicine Date:
Name
Position:
1. Current work/ duties (Details)______________________________________________
________________________________________________________________________
2. Animal models used / disease studied ________________________________________
3. Perform animal surgery?
No ____
Yes ____
If yes, frequency _____________________________
If yes, use of anesthetic gas? No ____ Yes ____ Isofluorane ____ Other _________
4. Use of: human blood/ fluids/ cell lines? No ____ Yes ____
If yes, what? __________________________________
5. Use of: organic chemicals (e.g., alcohols, solvents)? No ____ Yes ____
If yes, what? __________________________________________________________
Frequency _____________
6. Use of: carcinogens?
Amount _______________
No ____
Yes ____
If yes, what? Formalin solution ____ Ethidium bromide _____ Radiation _____
Other ___________________ Frequency _____________ Amount _______________
7. Use of: respirators? No ____ Yes ____ Type: N-95 _____ Other ___________________
Reason ___________________________________
__
8. Allergies: Animal _____ (Type) ______________________________________________
Respiratory_____
Type: Latex _______
None _______
9. Work-related health effects of any of the above?
No ____
Yes ____
If yes, please explain? ____________________________________________________
Occupational Health History Form Rev. 9/2011