TEXAS WOMAN’S UNIVERSITY
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE
PERSONNEL HEALTH STATUS FORM
All faculty, staff, and students working in the TWU Animal Facility should complete this form annually.
1. Review the entire form before completing it.
2. Seal the completed form in the manila envelope provided and write your name on the envelope, and
include your faculty advisor’s name in parenthesis.
3. Give the envelope to the Research Compliance Coordinator in Research & Sponsored Programs who
will ensure that the sealed document is delivered to the TWU Department of Student Health Services
where it will be placed on file and become a part of your confidential medical records.
Last Name:
First Name:
Date of Birth:
Middle:
Gender (M/F):
TWU Id. #:
Protocol Number(s) (if applicable):
Current Status (check all that apply):
Undergraduate
Graduate
GRA
Faculty
Staff
PI/Supervisor:
Department:
PI/Sup. Email Address:
PI/Sup. Ph. Number:
Contact Information
Present Address
Permanent Address
City/St./Zip:
City/St./Zip:
Phone: (
)
Ext.:
Phone: (
Email:
)
Email:
Emergency Contact
Personal Physician
Notify:
Dr:
Relationship:
Address:
Phone: (
)
Revised May 2016
Cell: (
)
Phone: (
)
ALLERGIES
Rats, mice, and chickens are housed in the Animal Facility.
Do you have known allergies to:
Rats or Mice?
Chickens?
Animal feed?
Latex?
Any other animal? (list)
Yes
No
If you have allergy symptoms such as shortness of breath, coughing, wheezing, skin problems, or other
reactions as a result of exposure to animals, please list.
Animal Species
Reaction(s)
Treatment necessary to alleviate
Are you sensitive to strong detergents or disinfectants?
Do you have environmental or plant allergies (pollen, ragweed, dust, etc.)?
If you have known allergies to any chemical or substance, please list.
Substance/
Reaction(s)
Treatment necessary
Chemical
to alleviate
Yes
Yes
No
No
Date of
last exposure
EXPOSURE TO ANIMALS
Complete the following section if you have had past and/or current contact with laboratory animals.
Include the level of exposure as defined in footnote.
Location (university, veterinarian facility)
From
To
Species
*Exposure
(mo./yr.) (mo./yr.)
Level
*
Level I: No direct contact but enters the animal facility.
Level II: Does not conduct procedures on live animals but handles “unfixed” animal tissues and fluids.
Level III: Minor exposure (handles, restrains, collection of specimens or administers substance to live
animals).
Level IV: Major exposure (performs invasive procedures such as surgery or necropsy).
Revised May 2016
Frequency of interactions with laboratory animals on the TWU campus
Daily
Weekly
Monthly
Less than monthly
Do you have frequent contact with?
Pets (if yes list type)
Farm Animals (if yes list type)
Yes
No
INJURIES
Have you ever had an adverse reaction as a result of an animal incident?
Yes
No
If yes, describe this or any other serious injuries inflicted on you by an animal. Include the approximate
date, the species of animal, a description of the circumstances and injury, and the treatment(s) received.
IMMUNIZATIONS
You must have a current tetanus vaccination (within the past 10 years) before you can work in the Animal
Facility.
Date of your most recent tetanus vaccination (attach documentation - required):
_____________
Tetanus vaccinations are available at:
 TWU Student Health Services, Hubbard Hall, (940)898-3826
 Denton County Health Dept., 535 S. Loop 288, Denton, Texas 76205, (940) 349-2900
 Your medical provider
Is there a medical or other reason you cannot be immunized against tetanus? No
Explain:
Yes
HEALTH CONDITIONS
List any health conditions that are pertinent to your work with animals, such as immune suppression,
pregnancy or attempting pregnancy, heart valve disease, splenectomy, chronic liver or kidney disease,
diabetes, malignancy, chronic back pain, asthma, seizures, HIV infection.
Revised May 2016
HEALTH HAZARDS RELATED TO ANIMAL CARE AND USE
CAUTION: Some infectious diseases, including certain zoonoses (disease of animals transmissible to
humans), are known to affect the fetus adversely. If you or someone in your household is pregnant or
planning to become pregnant soon, please discuss your risk level with a healthcare professional or your
personal healthcare provider prior to working with animals.
Animal dander, animal hair and other airborne substances, such as urinary proteins, may cause or
contribute to an allergic or respiratory condition. Therefore, people who work in an animal facility are
subject to such risk. Any animal user or animal facility worker who experiences: 1) an abrupt onset of
allergies or other respiratory problems or 2) a sudden increase in the frequency or severity of allergies or
other respiratory problems should consider exposure to animals as a possible factor in their illness. All
such incidents involving research lab personnel should be reported to the Principal Investigator; all others
should report an incident to the Animal Care Technician.
WAIVER
I decline completion of the TWU Personnel Health Status Form. I understand that my decision will
not affect my employment but may affect my access to the animal laboratory.
I understand the occupational risks of working with animals.
______________________________________________
Signature
_________________________
Date
I certify that the above information is true and complete to the best of my knowledge. I am aware that
misrepresentation may jeopardize my health. I understand the potential health hazards related to animal
exposure. If allowed to work in the TWU animal facility, I will abide by National Institutes of Health
guidelines for the care and use of animals and will NOT hold TWU or TWU personnel responsible for
any allergic or other adverse reactions which may result from my exposure to animals. I understand that I
may immediately stop my interaction with animals should I develop health problems related to exposure
to animals.
I understand that this form is confidential and will be kept on file at the TWU Department of Student
Health Services.
I will inform my instructor/supervisor if changes need to be made to the information in the form.
PRINTED NAME _______________________________________________________
SIGNATURE ______________________________________________ DATE _________________
Revised May 2016