Environmental Health and Safety
Eastern Michigan University
Department of Public Safety
103C Rackham
734.487.0794 Fax: 734.487.3449
ZOONOSES SURVEILLANCE QUESTIONAIRE
If you have contact with laboratory animals either as part of your job responsibility or as a student
involved with laboratory animals in your academic program, federal regulations require that you provide
the following information. Handling of laboratory animals does present the potential for injury or infection.
Eastern Michigan University is committed to provide a safe and healthy environment for animal handlers.
Based on your level of exposure to laboratory animals, you may be entitled to a physical examination.
You have the opportunity to receive a tetanus vaccination. These will be provided by the university at no
cost to you. Answers to the following questions are a part of your confidential medical records and will
not be disclosed to any party without your express consent.
Name:
Address:
Department:
Job Title:
EMU ID#:
Home Phone:
Date of Birth:
Supervisor:
Work Phone:
Type of Animal Contact (species handled, average number of hours/week with each species):
When did contact with laboratory animals begin?
Has exposure been continuous?
Within the past year, have you experienced any of the following? A yes or no answer is required for all
conditions below.
If yes, please give explanation and note if condition
is related to animal contact
Rashes
Allergies
Sinus problems
Breathing difficulties
(Shortness of breath, cough, wheezing)
Swollen lymph nodes
Fevers
Chills
Nausea
Diarrhea
Unexplained weight loss
Unusual illness
Have you been injured by an animal (animal bite, scratch, or other contact leading to symptoms)?
Species (Approximate date)
Bitten?
Infected?
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Do you have contact with animals outside of your job? (i.e. pets, wild animals, farm animals)
Have you ever suffered health problems that were attributed to your contact with animals? If so, please
describe. Any current problems?
Date of last tetanus vaccination:
Do you participate in a rabies vaccination program?
Last injection:
Type of vaccine:
Patient Signature:
Date:
RETURN THIS COMPLETED FORM TO YOUR SUPERVISOR
Supervisor-Complete the information below and direct this completed form to your IACUC Chair or
Supervisor.
Based on the potential for animal exposure, I recommend that this individual be considered for the EMU
health and safety surveillance.
This individual has selected/refused tetanus vaccination (form attached).
Name:
Telephone:
Department:
E-mail:
Signed:
Date:
IACUC CHAIR:
Sign and send this form to Health and Safety Office, Department of Public Safety, 107 Snow.
Signed:
Telephone:
Department/Division:
Date:
HEALTH and SAFETY OFFICE:
Sent to occupational medicine physician.
Physical exam scheduled
Date:
Denied
Reason:
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