OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET SECTION I: INITIAL QUESTIONNAIRE (TO BE COMPLETED BY APPLICANT) Received by OHP- Date/Initials: ________________________________ This form and any medical evaluations are to determine physical and mental ___ability to perform your role and whether the role might pose a risk to you. It is important that you provide complete information. Complete, print and sign Section I. Submit with a copy of immunization and/or titer records in a sealed envelope marked “OHP/CONFIDENTIAL” to Research Compliance (Room B157). Please complete the form in Microsoft Word. Use “Tab” to move among fields. If you need additional space, use a separate page labeled with your name, employee number and the question being answered. Please contact ohp@qatar-med.cornell.edu or 4492 8434 with any questions. 1. PERSONAL DATA Name Employee # Department Gender HC # Mobile # Job Title Date of Birth Lab PI Date of Arrival in Qatar City & Country of Residence Prior to Qatar 2. WORKPLACE EXPOSURE Please check those items you will have contact with because of your work at WCMC-Q. Animals Infectious agents Class III or IV laser Human fluids/tissues Animal fluids/tissues Chemotherapeutic agents Patients/ Research Subjects Radiation or radioactive materials Other: 3. EXPOSURE DETAILS For each item checked in Section 2, please provide the following information. Type (e.g., animal species) Frequency of Exposure Duration of Each Exposure 4. ANIMAL EXPOSURE OUTSIDE WCMC-Q Complete this section only if you checked “Animals” in Section 2 above. a. b. Do you have regular exposure to any animals outside the workplace, such as pets or farm animals? Yes No If you answered “Yes” above please describe the types of animals and your exposure to them: Version Date: August 28, 2013 Page 1 of 9 OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET Name: Employee #: HC #: 5. WORKPLACE HAZARD EXPOSURE HISTORY a. b. Have you needed medical attention or advice related to previous exposures to hazardous materials (including but not limited to, radiation, chemicals, animals, or human or animal tissues), or incidents (such as fire or smoke/fume inhalation)? Yes No If you answered “Yes” above please describe the exposure and the attention/advice needed. 6. GENERAL MEDICAL INFORMATION Question Yes/No Details (if Yes) a. Have you ever had a work-related injury or illness? Yes No b. Do you regularly use any tobacco products? Yes No List types, how often/how much, and how many years: c. If you answered “No” to question b above, have you regularly used any tobacco products in the past? Yes No List types, how often/how much, for how many years, and when quit: d. Do you drink alcohol? Yes No Weekly amount: e. Have you traveled outside Qatar in the past 12 months? Yes No List the countries and trip duration(s): f. Are you/your partner pregnant or planning to become pregnant? Yes No g. Do you have any physical conditions affecting your ability to perform duties or use personal protective equipment? Yes No 7. MEDICATION USE Yes No Do you routinely use any medications (including prescription medications, over-the-counter products, alternative therapies, herbal remedies and health supplements)? If yes, provide details below. Name Version Date: August 28, 2013 Dosage (Amount & Frequency) Purpose Page 2 of 9 OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET Name: Employee #: HC #: 8. IMMUNIZATION AND INFECTIOUS DISEASE HISTORY Please indicate which of the following vaccines and/or illnesses you have had and the approximate dates or ages at which you had them. Vaccine/Illness Vaccine? Illness? Date(s)/Age(s) Tetanus Diphtheria Whooping Cough (Pertussis) Measles (Rubeola) German Measles (Rubella) Mumps Influenza Smallpox Chickenpox/Shingles (Varicella) Rabies Hepatitis A Hepatitis B Hepatitis C Tuberculosis Anthrax 9. ALLERGIES AND/OR SENSITIVITIES Yes No Do you have any known allergies and/or sensitivities to latex (rubber products) or any medications, animals, chemicals, foods or plants? If yes, provide details below. Substance Symptoms Version Date: August 28, 2013 Treatment/Preventive Measures Page 3 of 9 OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET Name: Employee #: HC #: 10. REVIEW OF SYSTEMS Please review the following and check any that you are currently experiencing or have recently experienced. General Endocrine Skin Change in sleep habits Heat or cold intolerance Easy bruising Chills or fever Excessive thirst/hunger Persistent rash Fatigue/weakness Swelling in groin or armpit Swollen glands Poor healing Immunological Depressed immune system Heart Changes in moles or bumps Lungs Chest pain or tightness Cough/wheezing Vision changes Irregular heart beat Shortness of breath Hearing changes Heart murmur Ears/Eyes Heartburn unrelated to eating Vascular Leg cramps Bones & Joints Phlebitis Neurological Dizziness Fainting Abdomen Change in bowel habits Abdominal pain Back pain/injury/ surgery Diarrhea Limited motion Jaundice Pain, stiffness, swelling Ulcer disease Oral Nose/Sinus Headaches Metallic taste Infections Memory loss Mouth sores not healing Loss of smell Numbness/tingling Tremors Psychiatric Mood swings Nose bleeds Congestion but no cold Difficulty concentrating Depression 11. MEDICAL CONDITIONS Please review the following and check any that you have ever experienced. Anemia Angina Arrhythmia Asthma Blood transfusions Cancer Claustrophobia Chest injury/surgery Chronic bronchitis Diabetes Emphysema Epilepsy/seizures Heart attack Hernia High blood pressure Kidney disease Liver disease Lung disease Malaria Rheumatic fever Skin rashes Spinal/disk injury Thyroid disease Version Date: August 28, 2013 Page 4 of 9 OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET Name: Employee #: HC #: 12. MEDICAL CARE Question Yes/No Details (if Yes) a. Are you seeing or have you seen a physician or other healthcare provider for the item(s) checked in Sections 7 through 10? Yes No b. Have you ever been hospitalized or had an operation? Yes No If yes, when and for what? c. Have you ever been treated or evaluated by a mental health professional? Yes No If yes, when and for what? d. Have you ever had a skin test (PPD/Mantoux) for tuberculosis? Yes No If yes, when? e. Have you ever tested positive for tuberculosis? Yes No If yes, when? f. If you indicated in Section 7 that you have received the Hepatitis B vaccine: Did you have a complete series? Yes No Did you have a positive antibody titer? Yes No 13. SIGNATURE Please read the following information carefully and sign below. This form and any needed medical evaluations are required to determine your physical and mental ability to perform your role and whether your role might pose a risk to you. Completion of Occupational Health Program requirements is not a substitute for regular medical care. Employment or affiliation depends upon full disclosure of all your medical and mental health information. Any false or misleading statements can lead to dismissal. Healthcare professionals will assess the information you provide and examine and treat you (and/or recommend appropriate treatment and/or evaluation). The healthcare professionals might be from WCMC-Q or Qatar Foundation (QF) or from another organization on behalf of WCMC-Q or QF. These professionals will maintain medical records about you. Occupational health professionals have an ethical obligation to protect the confidentiality of these records and avoid unauthorized disclosure. Information from these records may be released within WCMC or WCMC-Q when relevant to safe performance of your duties, to other healthcare providers for treatment purposes, or as required by law. By signing below, I certify that: I understand the above information and authorize needed evaluations. My answers about my present or past health are complete and true to the best of my knowledge. I authorize the use of my health information as described above. SIGNATURE: Version Date: August 28, 2013 DATE: Page 5 of 9 OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET SECTION II: MINIMUM REQUIREMENTS (FOR REVIEW BY CLINIC) INSTRUCTIONS: Review Section I Review the information below according to type of exposure (see Section I) Complete indicated procedures and document results in Section III Non-Animal Care Staff with Animal Contact Procedure Minimum Frequency Animal Care/ EHS Staff Medical History/ Questionnaire Initial & Annual Physical Exam Initial As Indicated Tetanus/ Diphtheria/ Pertussis Vaccine1 Every 10 years Hepatitis B2 Initial 3 As Indicated Hearing Test Initial & Annual 4 Spirometry/ OSHA Questionnaire5 Initial & Annual As Indicated Rodent/ Aquatics Users Hazard/Agent Dependent Facilities As Indicated = Required (unless footnotes indicate otherwise) As Indicated = based on assessment or review of medical history 1 Determined by medical history Offered but not required. Employee must sign waiver if vaccination is declined. 3 Only rodent users where xenografts are performed/used 4 For staff working in areas with >85dBA noise levels (e.g., employees with cage wash duties) 5 Determined by medical history (e.g., lab animal allergies, hazardous agent use) 2 Version Date: August 28, 2013 Page 6 of 9 OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET SECTION III: EXAMINATION (TO BE COMPLETED BY CLINIC) INSTRUCTIONS: Conduct procedures indicated by your review of Sections I and II Complete this section Return this form to OHP or patient (with copies of lab results and vaccination records) Name: Employee #: HC #: EXAMINATION DATE: MEDICAL AND PSYCHIATRIC HISTORY: REVIEW OF SYSTEMS (INCLUDE UNEXPLAINED FEVER, RASH, COUGH, DIARRHEA, DIFFICULTY BREATHING): ALLERGIES (INCLUDING LATEX): MEDICATIONS: FAMILY HISTORY: SOCIAL HISTORY: HEALTH MAINTENANCE: Version Date: August 28, 2013 Page 7 of 9 OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET Name: Employee #: HC #: Height: Weight: BP: Pulse: Temp: Vision Left: 20/ Vision Right: 20/ Both Eyes: 20/ Corrected: Yes / No Color Vision: Pass / Fail General Appearance Normal Abnormal Comments Skin HEENT Neck/Thyroid/Carotid pulses Lungs/Chest Heart Abdomen/Inguinal Extremities/Joints Spine/Back/ROM Neurological/Gait IMPRESSION: ADDITIONAL TESTS/PROCEDURES PERFORMED: ADDITIONAL RECOMMENDATIONS: Version Date: August 28, 2013 Page 8 of 9 OCCUPATIONAL HEALTH PROGRAM MEDICAL CLEARANCE PACKET Name: Employee #: HC #: DISPOSITION: Continued clearance for duty requires freedom from any physical or mental health impairment which is of potential risk to the employee or others or which might interfere with the continued performance of duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances, which may alter behavior. Based on the information provided and the results of indicated evaluations and procedures, I determine that the above-named individual is: Cleared for Duty Not Cleared for Duty Cleared with Restrictions Respirator Clearance COMMENTS: Name/Stamp: Signature: Date: FOR OHP USE ONLY Complete packet includes following attachments: Yes N/A QA Needed Date Sent: Returned: Result: Copy to EH&S (p. 1 & this page only) Date Sent: Copy to Research Compliance (p.1 & this page only) Date Sent: Copy to Other (p.1 & this page only) Sent to: Notify PI/Lab Manager Date Done: Follow-up needed before annual clearance Date & Reason: Reminders set for follow-up/annual clearance Version Date: August 28, 2013 Date Sent: Date Done: Date(s): Page 9 of 9