Yes No - Oakland University

Route Campus Mail:
Attention: Nancy Jansen
Department: GHC Clinic
Oakland University
Health Review for Animal Handlers
Oakland University employees having laboratory animal exposure associated with their employment, study, or work on
an approved Institutional Animal Care and Use Committee (IACUC) protocol at this institution are required to undergo a
health review upon employment and at yearly intervals. A health review is recommended for all other research
personnel whose activities place them at reasonable risk of injury or illness, and who are involved in the direct care of
vertebrate animals and their living quarters, and those individuals who have direct contact with animals (live or dead),
their viable tissues, body fluids or wastes. Please complete this form and mail to Graham Health Center (2200 N Squirrel
Rd, Rochester Hills, MI 48309). Do not give this form to your supervisor. Please call the Biomedical Research Support
Facility (BRSF) at ext. 4440 & 4441, or Laboratory Safety & Compliance at 4314 if you have any questions.
First Name:
Last Name:
Home Phone:
Work Phone:
Student: ☐Yes
Job Title:
Home Address:
PI or Supervisor Name:
Supervisor Phone:
Health History
1. Do you now have or have you ever had any of the following:
Asthma? ☐Yes
Skin rashes, especially after glove use? ☐Yes
Allergy testing, injections or medications? ☐Yes ☐No
Chronic bronchitis, emphysema or COPD? ☐Yes ☐No
2. Immune system suppression? (Cancer, chemotherapy, radiation therapy, chronic
diseases, HIV, organ transplant, spleen removal.)
3. If yes to any of the questions above, please explain:
☐Yes ☐No
4. Have you ever been fit tested for a respirator?
If “Yes”, provide date tested:
5. Do you smoke tobacco?
☐Yes ☐No
6. Do you take any medications on a daily basis (including over the counter)?
☐Yes ☐No
☐Yes ☐No
If yes, please explain:
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Allergy History
Are you allergic to any of the following? (Check all that apply. Specify allergen for each item checked.)
☐ Chemicals:
☐ Latex:
☐ Trees:
☐ Wood :
☐ Food products:
☐ Perfumes:
☐ Tobacco smoke:
☐ Other:
☐Animals (specify):
Have you received emergency medical treatment due to an allergic reaction?
Have you ever needed medicine for an animal allergy?
If you are allergic to animals check all symptoms that develop when exposed to specific animals.
☐Skin rash
☐ Eczema or hives
☐ Sneezing
☐ Runny nose
☐ Nasal congestion
☐ Cough
☐ Runny nose
☐ Chest tightness
☐ Shortness of breath
☐ Wheezing
☐ Nose/ Throat Irritation
☐ Facial or tongue swelling
☐ Asthma
Other – List
Do you have allergic symptoms when you are NOT around animals?
Estimate the hours per day you handle animals:
☐ 0 hours
☐ 1 hour ☐ 2-4 hours
☐ more than 4 hours
Estimate the hours per day you work in the animal cage areas:
☐ 0 hours
☐ 1 hour ☐ 2-4 hours
☐ more than 4 hours
Indicate the task you perform while working in the animal cage areas:
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What Species of Animal(s) Do You Currently Work With?
Check all boxes that apply.
☐ Non-human Primates
☐ Pigs - swine
☐ Cows, Calves
☐ Sheep
☐ Horses
☐ Amphibians (Turtles, Frogs)
☐ Hamster
☐ Chickens
☐ Gerbils
☐ Guinea Pigs
☐ Goats
Other Mammals Currently Working With- Please List:
Reptiles (snakes, lizards)
Chicken embryo
Wild Rodents
Do you use environmental controls and personal protective equipment while working?
Specify: ☐Gloves ☐Surgical Mask ☐N95 Respirator ☐Other:
☐Yes ☐No
I understand that working with live animals may lead to the development of allergies and/or severe
asthma. I certify that the above information is complete and correct to the best of my knowledge and
belief. I authorize the GHC to contact my supervisor and release necessary information to control
exposures in the work environment if needed, based on the results of this health screening. I
understand that intentional misstatements or omissions may be grounds for disciplinary action which
could include termination. I understand that a health evaluation may be required.
For GHC use only: ☐form reviewed, animal handler cleared and department notified
☐recommend health evaluation, supervisor notified
Provider Signature
Patient Name
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Revised: 2/28/2012