Last Name:
Date of Birth:
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Initial Medical Surveillance Questionnaire
Occupational Health Program
University of Colorado, Denver
AMC | Downtown
Environmental
Health & Safety
You have been given the opportunity to fill out the attached medical surveillance questionnaire because you work with animals or have
potentially hazardous workplace exposures. The personal health and medical information provided by employees or applicants of
University of Colorado, Denver in this questionnaire is used by the Department of Environmental Health & Safety’s (EHS) Occupational
Health Program’s clinicians to establish a baseline medical history. All information is privileged and confidential. Submission of this
Initial Form as well as Annual Renewals is an Institutional requirement for entering research areas.
It is for your benefit that you answer all questions completely and honestly. Provide all information to the best of your ability. If you
have questions, please ask the health provider when you submit this form.
SUBMISSION INSTRUCTIONS: This form can be emailed, mailed or submitted in person. THE PREFERRED METHOD IS ELECTRONIC.
ADDRESS: Occupational Health Program, Mail Stop H275, 12348 East Montview Blvd., 2nd Floor, Aurora, Colorado 80045
EMAIL: Occupational.Health@ucdenver.edu PHONE: 303-724-9030
FAX: 303-724-9213
Section 1.0: PERSONAL INFORMATION
Name:
Female
Employee ID #:
Campus:
AMC
Downtown
Boulder
CSU
Other:
Dept.:
VA
DH
Work Phone:
UCD Email:
-
-
Male
Date of Birth:
Job Title:
Protocol Number(s):
Building and Lab Room #:
Today’s Date:
PI:
Type of animal(s) working with (or
N/A):
Speed Type:
Section 2.0: HOME ENVIRONMENT INFORMATION
The purpose of this section is to determine if you have lifestyle activities outside of the work place that may predispose
you to acquiring work related allergic and autoimmune responses while working with research animals.
1. Do you have indoor pets?
YES
NO
a. If YES, which animals and for how long?
1-2 years
2-3 years
3-4 years
> 4 years
Dogs
Cats
Other
2. Do you smoke cigarettes or other tobacco products?
YES
NO
a. If YES, how many years have you been smoking?
b. If NOT presently smoking, did you ever smoke?
YES
NO
c. If YES, what year did you stop smoking
and how many years did you smoke?
Section 3.0: OCCUPATIONAL ANIMAL and LABORATORY EXPOSURE HISTORY
The purpose of this section is to determine if you have work-related activities that may predispose you to acquiring work-related allergic
and autoimmune responses while working with research animals.
1. I perform animal handling or procedures in my new position.
YES
NO
2. I have worked with laboratory animals in the past.
YES
NO
a. If YES, how many months/years did you work with laboratory animals?
3. Will animals be present in your work area?
YES
NO
4. Check the boxes below to describe your handling of lab animals and other substances and how often you work with them.
Typical Contact Time
More than More than
Less than
New Job
Daily
3x/week
3x/month
12x/year
Hrs.
Min.
Fish/ Frogs (other aquatics)
Rodents (Mice, Rats)
Hamsters, Gerbils, Guinea Pigs
Rabbits
Squirrels
Prairie dogs
Cats, Dogs
Pigs
Sheep/ Cows
Goats
Horses
University of Colorado Denver Occupational Health Program www.ucdenver.edu/occhealth
V 1.3 23JAN2013
Last Name:
New Job
Date of Birth:
Daily
More than
3x/week
Non-human primate tissue
Unfixed animal tissue
Human cells, blood or tissue
Other:
5. Have you ever experienced an animal-related injury (including bites,
scratches or injuries involving cages or equipment) or contracted a
disease or infection from animals?
a. If YES, please explain:
More than
3x/month
YES
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Less than
12x/year
Typical Contact Time
Hrs.
Min.
NO
6. Are you or will you be using any agent from the following hazardous groups? (Check all that apply)
Recombinant DNA (rDNA)
Infectious agents
Radioactive material
Anesthetic gases
Teratogens/ Carcinogens
Heavy Metals
Anti-neoplastic drugs
Toxins/ Venoms
Other(please list):
Please list all substances being worked with:
7. Do you use or wear any of the following items when working in the lab?
a. Protective eye glasses
YES
NO
b. Mask/Respirator
c. Lab coat
YES
NO
d. Gloves
Section 4.0: MEDICAL HISTORY
1. Have you ever been diagnosed and treated for the following diseases? (Check all that apply)
Emphysema
Diabetes
Epilepsy
Chest Pain
Claustrophobia
Severe Facial Acne
Chronic Bronchitis
Pneumonia
Tuberculosis
Heart Disease
Rheumatic Fever
Irregular Heart Beat
Heart Murmur/Valve Disease
Kidney Disease
Chronic Back/ Joint Pain
Seizures
Arthritis
Loss of Consciousness
Other:
NONE OF THE ABOVE
2. Do you think you are allergic to any animals?
YES
NO
a. If “YES”, please list the animals:
Formaldehyde
Lasers
None of the above
YES
YES
NO
NO
Shortness of Breath
Stress/ Anxiety
Liver Disease
Cancer
High Blood Pressure
3. Do you have any of the following types of reactions around the animals listed above? Please check Yes or No.
Reaction
Current Reaction (In last 12 months)
Any Prior Reaction
a. Runny/Stuffy Nose
YES
NO
YES
Date:
b. Itchy/ Reddened Eyes
YES
NO
YES
Date:
c. Cough
YES
NO
YES
Date:
d. Wheezing
YES
NO
YES
Date:
e. Chest Tightness
YES
NO
YES
Date:
f. Shortness of Breath
YES
NO
YES
Date:
g. Hives/ Skin Rash
YES
NO
YES
Date:
h. Throat Swelling/ Difficulty Swallowing
YES
NO
YES
Date:
i. Difficulty Breathing
YES
NO
YES
Date:
4. Have you ever been told by a doctor that you have allergies?
YES
NO
a. If “YES”, what are you allergic to?
5. Do you have a reaction to latex?
YES
NO
6. Have you ever been skin tested for allergies?
YES
NO
a. If “YES”, what substances were you found to be allergic or sensitized to? (check all that apply)
NONE
Ragweed
Grass
Trees
Mice/Rats
Dust
Cats
Dogs
7. Have you ever received allergy (desensitization/immunotherapy) shots?
YES
NO
a. If “YES”, what year did you received the shots?
8. Have you ever had a pulmonary function test (Spirometry)?
YES
NO
9. Has a doctor ever said that you have asthma?
YES
NO
a. If “YES”, what year did your asthma start?
b. Are you currently taking medication (either over-the-counter or
YES
NO
prescription) to control your asthma?
c. If “YES”, what medications are you taking to control your asthma?
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Other:
Last Name:
Date of Birth:
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10. List any medications or treatments you are currently taking or have taken in the last year that cause immunosuppression
(steroids, chemotherapy, and transplant medication) or any heart/lung medications, or allergy/ asthma medications.
Name of Medication
Reason for Taking
Last time Taken
a.
b.
c.
d.
11. Are you currently on any work restrictions or limited duty?
YES
NO
a. If “YES”, please describe?
Section 4.1: MEDICAL HISTORY – IMMUNIZATIONS
1. Check the box and indicate the date(s) of most recent vaccinations or blood test to document antibody status.
The year is sufficient if the exact date is unavailable.
Tetanus vaccine (Td/ Tdap):
Influenza:
Hepatitis B:
or titer:
Hepatitis A:
Rabies vaccine:
or titer:
Date of Last Rabies Booster:
Q-Fever titer:
BCG (vaccine to prevent TB meningitis):
MMR (measles/mumps/rubella):
or titer:
Other:
Varicella (chickenpox):
or titer:
If not immunized for chickenpox, did you have chickenpox?
YES
NO
Date:
Section 4.2: MEDICAL HISTORY – TUBERCULOSIS SCREENING
1. Date of last PPD skin test:
Positive
Negative
a. If positive, date of last chest x-ray?
Positive
Negative
b. Did you receive Quantiferon Gold confirmation for a positive PPD test?
YES
NO
2. Are you experiencing any of the following symptoms?
Weight loss
Shortness of breath
Chronic cough
Bloody sputum
Fever
Section 4.3: MEDICAL HISTORY - FOR WOMEN ONLY
1. Are you pregnant?
YES
NO
2. Are you actively trying or planning to be pregnant within the next year?
YES
NO
There are various chemicals/ materials that are potentially hazardous to work with when pregnant. Please feel free
to discuss with us or your health care provider at any time.
Section 5.0: RESPIRATOR SCREENING
1. Have you been fitted for a respiratory protection device?
YES
NO
a. If YES, what kind and when:
N-95, Date:
½ Face, Negative Pressure Respirator, Date:
Full-Face Negative Pressure Respirator
Self-Contained Breathing Apparatus (SCBA):
Section 6.0: CONCLUSION
Do you have any concerns or questions about occupational health and
YES
NO
safety that is related to your job?
Please elaborate:
Section 7.0: CONSENT FOR EXAMINATION AND TREATMENT
I hereby authorize the health care professionals employed or contracted by the University of Colorado, to treat me and/or
recommend appropriate treatment and/or evaluation, and maintain medical records created as a result of such medical encounters.
This authorization includes permission to review my immunization and medical history, to obtain routine diagnostic tests if
necessary to provide me with any immunizations which may be required.
Failure to fill out and submit this form could result in denial of access to Institution animal research facilities.
Date:
Employee/Applicant Signature:
If submitting electronically type /S/ and print your name above. Email to: Occupational.Health@ucdenver.edu
Provider notes:
Education and Counseling on animal allergies
Hazardous group education provided
Referred for identified hazardous groups:
Counseled on injury/ first aid/ animal bites/
scratches procedures
Health Counseling
Recommend fit testing
University of Colorado Denver Occupational Health Program www.ucdenver.edu/occhealth
V 1.3 23JAN2013