Please complete this form, along with form B (Medical History Questionnaire)
Mail or deliver all forms to:
Concentra Medical Center
4205 Franklin Avenue, Waco, Texas 76710
To protect your privacy, please put all forms in a sealed envelope.
Health Risk Assessment Evaluation Questionnaire
For
Employee/Affiliate (participant) with Research Animal Exposure
Purpose: This form is provided to Principal Investigators (P.I.) or supervisors for the purpose of
identifying specific work exposures and potential health hazards in the work environment. This form is
used in conjunction with the Medical History Questionnaire for participants with Research Animal
Contact to determine what health and safety services or recommendations are appropriate for the
individual to work safely with research animals.
Instructions: The P.I. or supervisor must complete the form A for each individual under their supervision
with research animal contact. Both the PI and employee/participant must sign the completed A form.
The completed form A should be given to the participant to bring or send along with the completed
form B to the Concentra Medical Center. A signed copy of Form A should also be submitted to EHS
SECTION A: Employee or affiliate (participant) information.
Participant Name:
Click here to enter text.
Job Title: Click here to enter text.
Email Address: Click here to enter text.
Baylor ID #:
Click here to enter text.
Date of Orientation to Animal Research: Click here to enter text. Telephone: Click here to enter text.
NOTE for non-Baylor participants: Submit the completed Form A and attach your home institution
medical clearance for research animal contact. Send to the Concentra medical Center. If a medical
clearance form is attached, you do not need to complete Form B. If medical clearance documentation is
not attached, you must complete the B form (medical history).
Participant Status (check all that apply):
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Faculty
Visiting Scientist
☐ Staff
☐ Graduate Student
☐ Other: Click here to enter text.
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Undergraduate Student
SECTION B: Principal Investigator/Supervisor information.
P.I./Supervisor Name: Click here to enter text.
Telephone: Click here to enter text.
Email Address:
Click here to enter text.
Department: Click here to enter text.
SECTION C: Must be completed by P.I. / supervisor of employee or affiliate.
Is animal husbandry an essential part of the participants duties?
Yes
No
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(Continue on reverse side)
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BU OHSP Form A
Does the participant’s work require contact with:
Yes
 Human blood, tissues or cells in animals?
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Please list (specific type):
 Infectious agents in animals? (Including but not limited to virus, bacteria, fungi, ☐
protozoa or parasites.) Please list (specific agents): Click here to enter text.
No
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Biosafety level 3 (BSL-3) agents in animals?
Please list: Click here to enter text.
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Pregnant mammals (rodents excluded)
Wild-caught mammals or wild-caught birds
Venomous animals
Chemicals, including anesthetic gases, in animals.
If yes, list: Click here to enter text.
Will you be involved in any off-site animal work (e.g., field work)?
If yes, please provide: IACUC Protocol #: Click here to enter text.
List location(s): Click here to enter text.
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Species Contact: Identify all levels of exposure for each species or tissue for the participant named
above and check the appropriate column[s]. Check “0” if no direct or indirect contact.
Level 0 - No animal contact.
Level 1 - No direct contact, but enters area where research animals are used.
Level 2 - Does not conduct procedures on live animals but handles “unfixed” animal tissues and fluids.
Level 3 - Handles, restrains, collection of specimens or administers substances to live animals.
Level 4 - Performs invasive procedures such as surgery, necropsy
LEVEL OF EXPOSURE
LEVEL OF EXPOSURE
Species
0 1 2 3 4
Species
0 1 2 3 4
Amphibian
Birds
Fish
Gerbil
Guinea Pig
Hamster
Other
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Mice
Poultry
Rabbit
Rat
Reptile
Wild Rabbit/Mice/Rat
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List Other: Click here to enter text.
SECTION D: Supervisor certification
By signature, I certify that the information provided is accurate to the best of my knowledge.
PI/SUPERVISOR SIGNATURE
DATE
By signature, I acknowledge and agree with all of the above.
EMPLOYE/PARTICIPANT SIGNATURE
Date
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BU OHSP Form A
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