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Office of the Institutional Animal Care and Use Committee
Tel (909) 469-5241 * Fax (909) 469-5577
Occupational Health and Safety Program
Animal Care and Use Exposure, Hazard Identification and Risk Assessment
Introduction
Certain medical conditions can increase your potential risk of health problems when working with
animals or biohazardous materials. These conditions could include, but are not limited to, allergies to
animals or their dander, allergies to latex, asthma, chronic obstructive pulmonary disease (COPD), heart
valve disease and immunosuppression due to infection (e.g. HIV), metabolic disease (e.g. diabetes),
pregnancy or treatment with drugs or biologics (e.g. corticosteroids, anabolic steroids, chemotherapeutic
agents). This form is being used to help identify potential risks or health related issues so that appropriate
education, protective equipment and/or appropriate accommodations can be provided. Once you have
completed this form, you must sign and then submit it to the Student-Employee Health Office located on
the Pomona campus (address listed on the last page of this form). You may send a hardcopy by campus
mail or via fax. All health/medical information provided will remain confidential.
Identification Information
Today’s Date ___________________________
Name (print): ___________________________________Date of Birth: __________________________
Employee ID#: __________________________________Supervisor: ____________________________
Department: ____________________________________Email:_________________________________
Work Phone: ___________________________________Emergency Phone: _______________________
Health Care Provider (physician, nurse practitioner, etc.) _______________________________________
Health Care Provider Cell / Emergency Phone Number: _______________________________________
Occupational Risk Factors
1. Are you currently pregnant?
If yes, stop and refer to Occupational Health specialist.
No
Yes
2. Are you considering pregnancy in the next 3 months?
If yes, stop and refer to Occupational Health specialist.
No
Yes
3. What facility/location/room do/will you work in? _________________________________________
Rev. 2/24/16
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4. Are you presently listed on a research protocol?
No
Yes
If yes, who is the Principal Investigator and what is the protocol approval number?
________________________________________________________________________________
5. How long have you worked with animals?
0-1 years
1-5 years
6 or more years
6. What species or types of animals are you/will you be exposed to? ____________________________
_________________________________________________________________________________
7. Please check those items that you are/will be exposed to in the performance of your assigned job
duties.
Carcinogens/mutagens/teratogens
Infectious agents (bacteria, viruses, fungi, parasites, prions)
Ionizing radiation
Recombinant DNA
Toxic chemicals
Anticancer agents (list) __________________________________________________________
Anesthetic gases (list) ___________________________________________________________
Human-derived material (e.g., blood, tissues, cells from patients, cell lines) – Describe:
_________________________________________________________________________________
_________________________________________________________________________________
8. What personal protective equipment (PPE) do you use when working with laboratory animals? Check
all that apply.
Face Shield
Gloves
Head cover
Lab coat
Protective safety glasses/goggles
Respirator
Shoe covers
Surgical mask
Other – Explain:
______
__________________________________________
9. On average, how much exposure to laboratory animals do/will you have?
< 1 hour per week
1-8 hours per week
> 8 hours per week
10. Do you require any accommodations in order to perform your job duties?
No
Yes
If yes, please describe. _______________________________________________________________
Focused Health History: Allergies
11. Do you have a history of allergies?
No
Yes
Check all that apply.
animals
asthma
eczema
foods _______________________________
hives
latex
insects ___________________________________________
medications ____________________________________________________________________
seasonal rhinitis (“hay fever”)
trees, grasses molds
other _________________________________________________________________________
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12. Are you presently taking any medications for allergy symptoms such as itchy, watery eyes; runny
nose; sneezing; or, asthma?
No
Yes
If yes, list. _______________________________________________________________________
13. Have you ever had allergy testing performed?
No
Yes
If yes, what were the results? _________________________________________________________
Immunizations
* You must provide documentation of your previous immunizations/titers.
Immunization or Test
BCG (TB vaccine)
Hepatitis B (series of 3 shots)
PPD skin test for TB
Rabies (series of 3 shots)
Tetanus
Date Received
Titer Date
Titer Result
14. Have you ever had an adverse reaction to any of these immunizations? If so, please describe.
________________________________________________________________________________
________________________________________________________________________________
Present Health Status
15. Are you currently under the care of a healthcare provider for any medical condition or taking any
medications that could compromise your immune system? (See examples listed under Introduction)
No
Yes If yes, describe: ___________________________________________________
________________________________________________________________________________
16. Do you have any condition(s) that may compromise your respiratory function such as asthma,
COPD or chronic bronchitis?
No
Yes
If yes, list. ________________________________________________________________________
17. Do you have any health or workplace concerns not covered by this questionnaire that you feel may
affect your occupational health and would like to confidentially discuss with a healthcare
professional?
No
Yes
I certify that the above statements are true, complete and correct to the best of my knowledge.
_____________________________________________
Signature
Rev. 2/24/16
________________________________
Date
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Medical Clearance Form
From: Student-Employee Health
Dear Health Care Provider,
This patient, ____________________________________, has applied for or holds a position at Western University
of Health Sciences that will entail their being exposed either directly or indirectly to laboratory animals that may
carry microorganisms infectious to humans and might also require some heavy lifting up to 40 pounds. Based on
your knowledge of the patient’s medical history, please review the Animal Care and Use Exposure and Risk
Assessment form and then mark the most appropriate box below. If necessary, please provide any additional
information that you believe we should know in order for this patient/employee to perform their job.
I am not aware of any restrictions to this patient accepting such a position.
I believe that this patient may accept such a position but with the following restrictions:
______________________________________________________________________________
______________________________________________________________________________
The applicant should not accept such a position because the risks are unacceptably high.
______________________________________________________________________________
______________________________________________________________________________
Provider Signature:
________________________________________ Date: ___________________
Printed Name:
________________________________________
Provider Address:
________________________________________
________________________________________
Telephone Number:
________________________________________
Please mail the completed form to:
Western University of Health Sciences
Attn: Student-Employee Health Office
Western University of Health Sciences
479 East Second Street, BC, Room 110
Pomona, CA 91766-1854
Email: stu-emphealth@westernu.edu
Fax: 909-706-3785
Rev. 2/24/16