OHSP Attachment #3:
CONFIDENTIAL MEDICAL INFORMATION
SIGNIFICANT BIOLOGICAL AGENT OR ANIMAL CONTACT
HEALTH SURVEILLANCE QUESTIONNAIRE
Revision 12.12.2014
Grinnell College Student Health and Counseling Services
Date: ________________
P-Card #: _________________
Name: ________________________________________
Birthday: _________________
Email: ___________________________
Principal Investigator/Supervisor: _______________________________________________
Status:
Animal Handler
Investigator
Research Technician
Other: ___________________________
What species of animals or types of biological agents will you be handling?
Allergy/Medical History
Please list any medications that you are currently taking:
Are you allergic to any medications? __________ If yes, please list allergies and type of
reaction:
Do you have any allergies to any of the following (Check all that apply)?
Dog
Guinea Pig
Cat
Latex
Bird (feathers)
Trees
Rabbit
Grasses
Rat or mice
Alfalfa
Other Allergies ______________________________
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Do you currently deal with any of the following medical conditions (Check all that apply)?
Chronic cough
Hay fever
Recurrent Bronchitis
Rheumatic Fever
Diabetes
Cancer
Seizures
Asthma
Itchy, irritated eyes
Skin rash
Pneumonia
Tuberculosis
Heart Disease
Heart murmur & Valve Disease
Kidney Disease
Liver Disease
Loss of Consciousness
Gastrointestinal Disorder
Arthritis
Chronic Back or Joint Pain
Do you deal with any other type of chronic medical condition? If yes, explain.
Have you been told by a physician that you have an immune compromising medical
condition or are you taking medications that impair your immune system (steroids,
immunosuppressive drugs, or chemotherapy)?________
If yes, explain
Women Only:
Are you pregnant, or planning to be pregnant in the next year?
Yes,
No
If so, do you work with infectious agents or cats?
Yes,
No
Immunizations
Date of last tetanus booster: _______________ (If not within the last 5 years, SHACS will
revaccinate you)
Please call and make an appointment to see one of the nursing staff at SHACS #641-2693230. They will then help you complete the process and provide documentation that you
are cleared to participate in your animal handling/research. You are not cleared to
participate until this last step has been taken.
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