Office of Research Compliance
Institutional Animal Care and Use Committee
Institutional Animal Care and Use Committee
Animal Care Occupational Health & Safety Program
Employee Enrollment Form
The Boise State University Animal Care Occupational Health and Safety Program is a federal requirement
to ensure the health and safety of our employees with animal exposure. To fulfill this goal, please
complete the following risk assessment questionnaire pertaining to your animal related
research/studies/work at Boise State University. Information collected in this questionnaire is
confidential; the information may be reviewed by the university’s animal care occupational health
services provider.
Name:
Date:
Employee or Student ID #:
Date of Birth:
E-Mail:
Job Title:
College or Department:
Principal Investigator or Supervisor:
Work Phone:
Protocol #:
Role on the Protocol: ☐ P.I. ☐ Co-P.I. ☐ Lab Technician ☐ Research Assistant ☐Volunteer
☐ Other – specify:
Anticipated duration of work with animals:
What will be the extent of your exposure to animals at Boise State University?
☐
No direct contact
☐
Less than 8 hours per week
☐
More than 8 hours per week
What species of animals will you be exposed to at Boise State University? (Check all that apply)
Lab zebrafish
☐ Lab mice or rats
☐
☐ Lab birds
Arthropods (list):
Wild birds (list):
Lab or wild amphibians,
☐
☐
☐
reptiles, wild fish
☐ Wild mammals (list):
☐ Lab rabbits
Principal Investigator/Supervisor Certification
By signature, I certify that the information is accurate, that I have provided or will provide prior to
animal exposure the participant named above with the appropriate training and will communicate the
associated risk for the animals they will be working with. The appropriate personal protective
equipment will be provided to the participant at no charge.
Printed Supervisor Name:
Supervisor Signature:
04/30/2013
Date:
Office of Research Compliance
Institutional Animal Care and Use Committee
Read Occupational Health & Safety Program
All employees must read the OHS program and appropriate species related information.
☐
I have read and understand the Boise State University Occupational Health & Safety Program and
the appropriate species related information.
Personal Risk Factors:
Many medical and physical conditions increase an individual’s risk of adverse health and safety
outcomes associated with animal care and use facilities and animal contact. Some examples of medical
conditions that require extra precautions are the following: animal allergies, asthma, pregnancy,
immunosuppressive therapies, etc. Such conditions do NOT preclude you from working with animals or
in an animal facility, but may necessitate additional precautions and occupational health and safety
evaluation.
Participants are strongly encouraged to be current on all vaccinations normal for their age group as this
is one of the most important aspects of a preventative medicine program. It is of particular importance
for animal workers to be protected against tetanus. A tetanus booster is needed every ten years.
Participants have the opportunity to complete a health history questionnaire and discuss exposure risks
with an occupational health services provider.
Each employee must determine whether or not they wish to complete the health history questionnaire
and discuss their animal exposure with an occupational health services provider by signing one section
below .
Participant Certification
I have or plan to complete the Health History Questionnaire and wish to discuss my animal exposure
with an occupational health services provider.
Printed Participant Name:
Participant Signature:
Date:
OR
Participant Declination
I have been informed that due to my exposure to animals, I may be at risk of acquiring a zoonotic,
allergic, or animal related disease. I decline the opportunity to complete the Health History
Questionnaire and discuss my animal exposure with an occupational health services provider. I
understand that in the future, I can request to complete the Health History Questionnaire and discuss
my animal exposure with an occupational health services provider at no cost.
Printed Participant Name:
Participant Signature:
04/30/2013
Date: