University of North Texas
MEDICAL HISTORY QUESTIONNAIRE FOR INVESTIGATORS, TECHNICIANS, STUDENTS, &
OTHERS EXPOSED TO LABORATORY ANIMALS
Individual’s Name:
Principal Investigator’s Name:
UNT Department:
Date Questionnaire Completed:
UNT MEDICAL HISTORY QUESTIONNAIRE FOR
INVESTIGATORS, TECHNICIANS, STUDENTS & OTHERS EXPOSED TO
LABORATORY ANIMALS
Completion of this questionnaire is an annual requirement for working with laboratory animals or animal
tissues or having access to any animal laboratory on campus.
COMPLETE ALL INFORMATION-INCOMPLETE FORMS WILL NOT BE ACCEPTED
Identification
Last Name
First Name
Date of Birth
______ (MM/DD/YY)
IACUC Protocol Number(s)
Middle
Gender _______
(M/F)
_________________________________________________________
Principal Investigator:
Department:
Principal Investigator’s Phone Number:
______
Contact Information
Campus Address
Permanent Address
Bldg/Room
Extension
City
E-mail
Phone
In Case of Emergency
Personal Physician
Zip
Notify
Relationship
Facility
Phone
City
Date of most recent physical exam
(MM/DD/YY)
Current Status (check all that apply):
Student:
Staff
Faculty
Undergraduate
Graduate
Other
1
Exposure Level (see description of Levels below)
Species
Level of Exposure
I
II
III
IV
I
II
III
IV
Birds/Poultry
Other
________
Rodents
Other
________
Rabbits
Fish
Frogs
Gerbils
Hamsters
Other
________
Level I
No direct contact but enters animal laboratories.
Level II
Does not conduct procedures on live animals but handles “unfixed” animal tissues and fluids.
Level III
Minor exposure (handles, restrains, collection of specimens or administers substance to live
animals).
Level IV
Major exposure (performs invasive procedures such as surgery or necropsy).
CAUTION: Some infectious diseases, including certain zoonoses, are known to adversely affect
fetuses. If you or someone in your household is pregnant or planning to become pregnant soon,
please discuss your risk level with a health care professional at the UNT Student Health and
Wellness Center or your personal health care provider prior to working with animals or animal
tissues.
Risk of Injury (Check One)
Low Risk
Fish or amphibians
Mild Risk
Rats, mice, rabbits, guinea pigs, hamsters, gerbils, and birds with risk of injury
(primarily bites and scratches), zoonotic diseases, and significant potential for allergies.
Moderate Risk
Wild rodents with moderate risk of injury (primarily bites and scratches),
zoonotic diseases (rabies, Q Fever, hanta virus, Bacterial and fungal
infections) and significant potential for allergies.
Section A: Medical History
1. Are you allergic to latex, animal feed, or substances/chemicals used for work
with live animals or animal tissues?
Material/Substance/
Chemical
Reaction(s)
Frequency
Yes ______
No _______
Severity
2
2. Do you have any health conditions that are pertinent to your work with animals Yes _____ or
No ____
or animal tissues, such as immune suppression, pregnancy or attempting
Possibly _____
pregnancy, heart valve disease, splenectomy, chronic liver or kidney disease,
Yes
diabetes, malignancy, chronic back pain, asthma, seizures, or HIV infection? If
“yes” or “possibly yes,” describe below.
3. Insert the date of your most recent vaccination for tetanus (check with your health care provider if you are
unsure of the date). If you have not had a tetanus vaccination or cannot verify the date, mark the appropriate
column.
Immunizations
Month/Day/Year
No Vaccination
Cannot Verify
(Tetanus (booster)
4. Have you ever contracted a serious illness from an animal or had an animal
inflict a serious injury?
No ____
Yes _____ or
Possibly _____
Yes
5. Have you ever had any problems (such as allergy symptoms, shortness of
breath, coughing, wheezing or skin problems) as a result of exposure to
animals?
No ____
Yes _____ or
Possibly _____
Yes
List Animal Species
Reaction(s)
Frequency
Severity
6. Will you be working with human blood, body fluids or tissue?
Yes
No If “yes”, please describe: __________________________________________________
Training
I have completed the required CITI basic Working with the IACUC training course and the speciesspecific training courses for the species I will be working with.
Yes
No
3
Section B. Signature of Employee or Student
Please read the following, sign and date before submitting.
The above information is true and complete to the best of my knowledge and I am aware that
misstatements or omissions may jeopardize my health.
Signature of Employee or Student
Date
Section C: Authorization for Release of Recommendations to Principal Investigator
I authorize the UNT Student Health and Wellness Center to release any recommendations from its reviewing
physician to the Principal Investigator for the animal research projects that I will be working on. I understand
that any such recommendations will not include any information regarding my health history or diagnoses
but will be limited to communicating restrictions, inoculations needed, or other recommendations regarding
my contact with live animals or animal tissues at UNT.
Signature of Employee or Student
Date
Section D: Signature of Employee or Student Declining Participation in the Program
If you have decided not to complete this questionnaire and not to participate in this aspect of the program,
please date and sign this block. This will have no effect on your employment. However, it may affect your
access to facilities where laboratory animals or animal tissues are housed. At any time that you decide to
participate in the Occupational Health and Safety Program you may do so.
Medical History Questionnaire Waiver
I decline participation in the Medical History Questionnaire review process for animal workers at this time.
I understand the occupational risks of working with animals and animal tissues.
Signature of Employee or Student
Date
Enclose this questionnaire in a sealed envelope with your name and your Principal Investigator’s name
on the outside. Send/bring to the IACUC staff in the Office of Research Integrity & Compliance,
Hurley Administration Building Room 185A. The sealed envelope containing the questionnaire will
be hand-delivered by the IACUC staff to the UNT Student Health and Wellness Center for review by one
of its physicians.
For UNT Student Health and Wellness Center Use Only
Reviewed by
Date
Comments
__________________________
_______________________________________________________________________________________
Recommended Precautions Communicated to Principal Investigator (on Date_________________________)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
4