Animal Exposure Health and Safety Evaluation
Employee Name:
Page 1
Employer: _
Today's Date:
Month and Year you began working in the Animal Lab: _
Please Circle the animals that you work with, and mark with an X any duties performed by you. Indicate if you spend
more than 10 hours per week with the animals, and indicate with an X any symptoms that you are experiencing.
Animal
Handle
Feed
Change
Bedding
Clean
Cages
More than
10
hours/week
Rhinitis/Runny
nose
Cough
Congestion
Mice
Rats
Birds
Frogs
Fish
Lizards
Turtles
Do you have any pets at home? Yes
No_
If yes, what kind?
Do you have any health problems related to contact with your pets? Yes
If so, what?
No
Asthma
Shortness
of Breath
Rash
Animal Exposure Health and Safety Evaluation Page 2
Name
Do you have now, or have you ever had any of the following:
1. Eczema, rash, hives or other skin problems
2. Rheumatic fever or rheumatic heart disease, heart
murmur or disorder of the heart valve
3. Asthma or other chronic pulmonary disease
4. Splenectomy, absent or non-functioning spleen
5. Sickle cell anemia
6. Recently taken medications or therapies which might
suppress the immune system (for example, prednisone,
cortisone, Humira, chemotherapy, radiation)
7. Other medications you are taking
Best Phone Number to reach you: _
No
Yes
Please explain all YES answers here:
8. Chronic medical problem that might suppress the immune
system, for example, cancer, leukemia, lymphoma, diabetes,
HIV or AIDS, tuberculosis, liver or kidney disease,
alcoholism
9. Allergies to medicines
10. Allergies to any animals
11. Skin test for allergies
12. Other allergies, including latex-related
13. Tetanus toxoid booster: give date of most recent
vaccination
14. Tuberculosis testing – TB skin test, Quantiferon-TB Gold
test or chest x-ray: specify test and give date of most recent
test & result
15. Some research related or animal biohazards have
adverse effects on pregnancy. Are you pregnant or planning
to become pregnant in the next year?
16. Do you experience an allergic reaction from indirect
environmental exposure to areas of animal housing or use?
I answered the above questions truthfully and to the best of my ability.
Signature of employee/student
Date
Reviewing Healthcare Provider Signature and Title
Date