Occupational Health & Safety
Laboratory Animal Resources
Health Questionnaire - Part 1
For new employees, students, and all others working with animals
Date of anticipated completion of work in an animal lab and/or field work
Section 1: Personal Information - Please Print
____
B#
Date of Birth ____________
Contact Information
Last Name
First
Middle______ Sex:
M
F
Home Address
City
State
Zip
Local/Campus Address _________________________________________________________________
Cell /Local phone
Email
In Case of an Emergency
Name of Primary Care Physician __________________________
Person to be notified ____________________ Relationship
Phone ______________________
Phone
University Department Information
Department ____________________________
Supervisor’s Name _
Lab or Class enrolled in ________________________________________________________________
Section 2: Risk Assessment
1. Employment Status
Animal Handler/Technician
Veterinary Staff
Faculty
Undergraduate Student
Post Doctorate Research Associate
Graduate Student
Research Assistant
Other (list job description) _____________________________
2. Please check each of the animal species with which you intend to work:
Rat
Mouse
Reptile
Rabbit
Bird
Other species
3. Please check the box below which approximates the time you plan to spend:
Working in an animal lab
and/or
Doing field work
Daily (number of hrs/day)
Weekly
Monthly
Rarely (Less than once a month)
Not handling animals but working in the Animal Laboratory environment (please explain)
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Caution during Pregnancy:
Exposure to radioactive materials, certain chemicals, and infectious agents (including zoonoses) may potentially affect
Page 1 If you, or someone in your household/dorm room
the fetus adversely during any or all stages of fetal development.
is pregnant or planning to become pregnant soon, it is your responsibility to contact Dr. Diane Paukett, Phone
(607)777-4610; email: lpaukett@binghamton.edu This information will be used to update your risk assessment and to
make any necessary recommendations.
.4.
Have you worked with animals prior to attending/joining Binghamton University?
Yes
No (If yes, please provide the following information on any relevant exposure or need for
continued medical surveillance):
Prior Institution/Lab/Clinic/Research Facility: ______________________________________________
What exposed to: ______________________________________________________________________
What illness, disease, or condition are you being monitored for?
N/A
______________________________________________________________________________
5. Have you ever contracted a disease from animals or experienced an animal-related
injury (bites, scratches, needlestick, etc.)? Yes
No
If yes, please describe: ____________________________________________________________
______________________________________________________________________________
Section 3: Work Restrictions
Do you have any medical problems or disabilities that might affect your ability to perform your studies or
work safely, or that might create potential hazards for others?
Yes
No
(If yes, please describe):
Do you have any work restrictions?
Yes
No (If yes, please list restrictions):
** (You will need to provide a copy of all work restrictions from your healthcare provider, prior to being certified
to work in the Animal Laboratories) **
Do you require any accommodations in order to perform your job or studies?
(If yes, please list):
Yes
No
Section 4: Immune Status
Section4
Have you been told by a health practitioner that your immune system
is suppressed or compromised?
Yes
No
Do you have a history of cancer?
Yes
No
Are you currently on immunosuppressive medication?
(For example, steroids, immunosuppressive drugs or chemotherapy)
Yes
No
Notice: If over the course of the year, you develop an illness, disease, condition, or are started on medication that
you are told suppresses or compromises your immune system, it is you responsibility to contact Dr. Diane Paukett.
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Section 5: Baseline Medical History
Have you ever been told that you have any of the following conditions?
Heart Conditions:
Musculoskeletal Conditions:
Valvular Heart Disease
Congenital Heart Disease
Heart Palpitations/Arrhythmias
Rheumatic Fever
Other Heart Condition
Back Injury or Chronic Back Pain
Hernia
Arthritis
Lyme Disease
Chronic Muscle or Joint Problems
Respiratory Problems:
Chronic Bronchitis
Pneumonia
Other Lung Disease
Upper Respiratory Problems:
Asthma
Chronic Cough
Tuberculosis
Hay Fever
Colds (frequent)
Sinusitis
Seasonal Rhinitis
Mental Illness:
(If yes, please list diagnosis):
_________________________________
Chronic Conditions:
Diabetes
Eczema
Chron’s Disease
Irritable Bowel
Psoriasis
Ulcerative Colitis
History of Alcoholism and Drug abuse?
Yes
No
Hearing Problem?
(If yes, is a Hearing aide worn?)
Yes
Yes
No
No
Neurological Conditions:
Dizziness, Fainting
Seizure Disorder
Visual Problem?
Yes
(If corrective lenses worn, list, type)
*Safety glasses available:
Yes
No
No
If there is a history of Respiratory or Upper Respiratory Illness or symptoms, please complete the
Respiratory Illness Questionnaire - Part 3
Section 6: History of Allergy
Allergies: - Check all that apply:
Medications
Dust
Animals
Mold
Latex
Food
Pollens
Other______________
(If you have a history of allergies, please describe the symptoms you have with each specific
allergy)._______________________________________________________________________
Have you ever had an anaphylactic or life-threatening allergic reaction?
Yes
No
(If yes, please describe the cause, symptoms and severity of the reaction)
______________________________________________________________________________
Do you have any of the following symptoms chronically or intermittently?
Chronic cough
Wheezing
Shortness of breath
Chest tightness
Skin rash, dermatitis
Hives, urticaria
Open wounds/ skin ulcers
Itchy, red eyes
Diarrhea
Nausea
If there is a history of Allergy or Allergy symptoms, please complete the Allergy Questionnaire Part 2
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Immunizations:
1. Tetanus:
Received vaccination
Yes
No
Date of vaccination
/
/
Received Booster
Yes
No
Date of Booster
/
/
Tdap or
Td
Note – Tetanus boosters are recommended every 10 yrs.
2. Hepatitis B:
Received vaccination
Yes
No
Date of vaccination
/
/
Received Booster
Yes
No
Date of Booster
/
/
Allergy Questionnaire – Part 2
Please complete this section if you checked any of the boxes in Section 6 or
if you have a history of allergy problems
If not applicable
check box
1. Is there a family history of allergies?
Yes
No
If yes, please describe: __________________________________________________________________
2. History of allergy symptoms
Please check if you presently have or have ever had any of the following symptoms or problems:
Nasal congestion
Eczema, Atopic, or Contact Dermatitis
Hives
Postnasal drip
Steven Johnson Syndrome
Sneezing
Chronic cough
Itching or drainage of eyes
Wheezing
Chest tightness
Anaphylactic Reaction (If yes, list cause of this severe Allergic reaction):
3. If you have a history of a severe allergic reaction, please check all that apply:
Where reaction was treated
Office or clinic
Emergency Room
If admitted, to what Hospital:
__________________________
__________________________
__________________________
What treatment was given
Epinephrine
Steroids (Check type):
IV
Oral
Oxygen (Check type):
Mask
Nasal
Aerosolized Albuteral Nebulizer Treatment
Required Ventilator support
Required Cardiac Monitoring
Other treatment (Please describe): ____________
__________________________________________
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4. History of allergy testing
Have you had any allergy testing done in the past?
Yes
No
Where was allergy testing performed? (Name of allergist or clinic)
___________________________________________________________________________________
If yes, what testing was done? (Check all that apply)
Skin testing
Results: _______________________________
RAST Test
Results: _______________________________
ELISA
Results: _____________________________
5. History of allergy treatment
Please list all medications you have used for treatment of your allergic condition or symptoms:
Medication
Using at present?
Yes
No
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Have you ever received Allergy shots?
Yes
No
If yes, list what allergens the shots were being used to treat: _________________________________
__________________________________________________________________________________
List when you received allergy shots or the total number of years that you received shots:
__________________________________________________________________________________
Did you ever have a severe reaction to an allergy shot?
Yes
No
If yes, please describe: _______________________________________________________
Respiratory Illness Questionnaire – Part 3
If not applicable
check box
Please complete this section if you have any history of respiratory
symptoms or conditions
1. History of Respiratory Symptoms
Please check if you have or have had any of the following symptoms:
Nighttime cough
Shortness of breath with exercise
Shortness of breath at night
Chest tightness
Chronic cough
Wheezing
If yes, when did this problem start?
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If there is a history of wheezing please check all items below that apply:
Symptom
Freq/day
Freq/week
Freq/year
Nighttime wheezing
Daytime wheezing
Wheezing with exercise
Wheezing with shortness
of breath
2. History of Medical Treatment
Please list all medications you have used for treatment of your respiratory symptoms:
Medication
Using at present?
Yes
No
3. Smoking history
Do you smoke or have you ever smoked in the past?
If yes:
Yes
No
How many cigarettes or cigars?
How many years have you smoked for?
When did you start smoking?
When did you quit smoking?
Yes
No
If yes, please explain: ________________________________________________
Are you exposed to second hand smoke at home or elsewhere?
4. History of Respiratory Testing
Have you ever had a pulmonary function or spirometry test?
Yes
No
If yes, how long ago and where was test performed? _________________________________
If you know the results of this test please describe: __________________________________
**If you have a copy of your most recent pulmonary function or spirometry test please submit a copy
to Occupational Health and Safety – LAR **
5. History of use of Personal Protective Equipment
Have you ever been fit-tested for a mask?
Yes No
If yes, what type of mask? __________________________________________________
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Signature
**Confidential Medical Information**
This information is strictly for the use of the Occupational Health and Safety Program of
Laboratory Animal Resources and may not be released to anyone without your written consent.
I attest that the information above is correct to the best of my knowledge.
I understand and give permission for this information to be entered in a confidential,
centralized database for purposes of reducing risk of exposure to vaccine preventable
diseases, allergens, zoonotic diseases, and bloodborne pathogens.
Signature ________________________________
Date
________________________________________
Signature of Parent or Guardian (if under 18)
Date ___________________
Please return form in an envelope marked confidential to:
Penny Evans
Binghamton University
LAR
P.O. Box 6000
Binghamton, NY 13902-6000
Reviewer Signature _________________________________
Date ___________________
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