MIDWESTERN UNIVERSITY (MWU)
Animal Facility Medical Monitoring Program – VISITOR FORM
Acknowledgement, Acceptance/Declination Statement
(This form should be used when any non-MWU employee or non-MWU student wishes to enter the animal facility, including but not
limited to visitors, outside contractors, and inspectors)
Completion of this form is required for all non-MWU employees or non-MWU students who enter the animal facility. Failure to
complete the form may result in the loss of privilege to enter the Animal Facility. Complete part 1 and part 2.
Part 1: Acknowledgement and Acceptance/Declination
1.
I have received and understand the “Occupational Health Program for Animal Users” (see pages that follow). This
form and program can be obtained from the Office of Research and Sponsored Programs or Human Resources
Department.
2.
I understand that a Tetanus immunization is normally recommended for all persons having animal contact, but since I
am not anticipated to come into contact with animals during this limited visit, a Tetanus immunization is not
recommended.
3.
I understand that my limited entry into an Animal Facility could pose a health risk, and I should pay attention to any
changes in my health status, especially allergies.
4.
In full recognition of the above:
I agree to abide by the Midwestern University “Occupational Health Program for Animal Users”, to the
extent that it applies to me.
5.
Allergy status:

I have no known allergies to animals. I understand that it is recommended that I pay attention to my allergy status,
particularly if I repeatedly enter animal facilities at multiple institutions. OR
I have allergies to animals and I’m enrolled in a Respiratory Protection Program at
________________________________________________. I have been fit tested for my own personal protective
equipment (i.e. a mask) and will bring it to wear while in MWU’s Animal Facility to minimize risks associated with
allergies. OR
I have allergies to animals and I’m not enrolled in a Respiratory Protection Program elsewhere.
 Visitors who fall into this category will be made aware of the “Basic Facts about Exposure to Research
Animals at MWU”, but due to the one-time or limited exposure to animals, will not have a comprehensive
risk analysis performed at Advocate Occupational Health.
 Wearing a mask to minimize exposure to animals while in MWU’s Animal Facility will be recommended,
and disposable N-95 masks in various sizes will be available on a voluntary basis (no medical assessment
or fit testing will be performed).
 By signing below, I acknowledge my understanding that wearing a N-95 mask may not fully protect me
from an allergic reaction.
 Visitors who understand and accept the risks, but voluntarily decide not to wear a mask, will be asked to
sign a “Visitor - Waiver, Release, and Assumption of Risk Form”.
Part 2: Information (Please Print in the Table)
Name of Visitor
Date
Name of Employee who will accompany visitor into the Animal Facility
Phone of MWU Employee
Department of Employee who will accompany visitor
Email of MWU Employee
Signature of Visitor
______________________________________________________
Signature of Respiratory Protection Program Administrator
Signature of Employee who will accompany visitor
Revised 2/12
Occupational Health Program (OHP) for Animal Users
The health of individuals working in the Midwestern University Animal Facility is an area of concern to the
University and its administration. As such, we have developed the following occupational health and safety program and
procedures as a guide for all those who enter the Animal Facility. It has been designed using current federal guidelines
(Institutional Animal Care and Use Committee Guidebook from The Office of Laboratory Animal Welfare (OLAW) of the
NIH as well as the Guide for the Care and Use of Laboratory Animals published by the NRC) to minimize the risks
associated with animal use. General oversight and operational responsibility for MWU’s OHP ultimately rests with the
Institutional Official. In this role, the Institutional Official relies upon MWU’s Respiratory Protection Program
Administrator, Human Resources, Risk Management and/or the health care professionals of Advocate Occupational
Health.
I.
Who will be involved?
All persons who enter the animal facility at Midwestern University will be required to fill out a Animal Facility Medical
Monitoring Program Form (there are 3 different forms, one appropriate for MWU Employees, MWU Students or
Visitors). The answers provided on that form, in conjunction with the anticipated extent of duties and/or anticipated
number of times and duration the individual will enter the animal rooms, will determine the extent of enrollment in the
OHP for Animal Users. Signage will be posted on the doors of the animal facility stating EVERYONE
(faculty/staff/students/maintenance/security/visitors, etc.) who enters this Animal Facility MUST be risk assessed by the
Animal Facility Medical Monitoring Program Form and receive the Occupational Health Program for Animal Users. If you
have not completed this, or if you are not sure if you completed it, then please contact the Manager of Animal Resources.
The Animal Facility Manager will help Human Resources in assuring that all people participate in this program prior to
gaining ID access to the facility.
II.
Hazard identification and risk assessment
Step one is that all who enter MWU’s Animal Facility will have a preliminary risk assessment performed by filling out a
Animal Facility Medical Monitoring Program Form. If deemed necessary by the Respiratory Protection Program
Administrator, based on the history of animal allergies and the anticipated intensity, duration, and frequency of exposure
to hazards posed by the animals and/or materials, the individual may be required to perform a more comprehensive risk
assessment. Individuals with one-time or very limited access privileges to the animal facility may not be required to have a
comprehensive risk assessment.
When necessary, the second step of a comprehensive Risk Assessment is performed by the health care professionals at
Advocate Occupational Health. They have the collective expertise to perform a comprehensive health risk assessment,
starting with a medical evaluation questionnaire. The questionnaire used is an OSHA mandated document which requires
detailed information about your current/previous medical conditions. No MWU employee will see your responses to this
questionnaire. Upon completing this information, the health care professional and/or the individual being risk assessed
may request a meeting to address current health conditions, risks for conditions such as allergies and zoonotic diseases,
any symptoms the individual may be experiencing, and any concerns either may have. You may be referred to specialists
for additional testing.
A small number of employees, usually limited to the animal facility staff who frequently handles animals, bedding, and
animal waste, will be required to perform annual physical exams and discuss any occupational health related issues with the
health care providers at Advocate Occupational Health.
If Advocate Occupational Health professionals determine that the risks associated with a particular individual cannot be
reduced to an acceptable level, the Respiratory Protection Program Administrator and the Institutional Official will be
notified. The Institutional Official reserves the right to deny an individual the ability to enter the Animal Facility, if it is
deemed in the best interest of the university and/or the individual.
III.
Potential hazards at Midwestern University
Allergy and musculoskeletal injury constitute the vast majority of health risks to individuals using and caring for laboratory
animals. Infectious diseases also form a significant risk depending on the species and health status of animals involved and
the level of exposure to them by animal care personnel, faculty, and technical staff. Animal bites and scratches are also
common hazards. As a guide, the following table has been adopted from the OLAW Institutional Animal Care and Use
Guidebook and should be used in constructing guidelines for those submitting animal use protocols.
OCCUPATIONAL HEALTH PROGRAM FOR ANIMAL USERS
Extent of animal contact:
Direct Contact with
Limited Exposure
( 8 hrs/week)
Species Used and
Other Risk Factors
Direct Regular Contact
( 8 hrs/week)
Small animals
(Rabbits, rodents,
birds, etc.)
1, 2, 5
1, 2, 5
Dogs, cats, and
feral animals*
1, 2, 4
1, 2, 4
Primates*
1, 2, 3, 8
1, 2, 3, 8
Farm animals*
1, 2, 6
1, 2, 6
Amphibians, reptiles
fish, etc.*
2
2
Infectious disease
agents Biosafety Class
III or higher*
1, 2, 7, 8, 9
1, 2, 7, 8, 9
No Direct Contact
(Occasional Exposure)
3
1, 2, 7, 8, 9
Work with animal
tissues
7
7
7
_____________________________________________________________________________________________
Code number Procedure
1
2
3
4
5
6
7
8
9
Pre-employment physical exam
Tetanus prophylaxis
TB test every 12 months
Rabies immunization
Pre-employment allergy history and education
Special education on large animals diseases
Special consideration by IACUC and Biosafety Committee subcommittees
Post-employment physical exam
Annual physical exam
*It should be noted that historically, the vast majority of animals used at Midwestern University have fallen under
the heading of Small Animals (to include Rodents, Rabbits, Guinea pigs, etc.). We do not use dogs, cats, primates, farm
animals or other large animals.
IV.
Training of personnel
All employees and students who work with animals will receive “The Basic Facts about Exposure to Research Animals at
Midwestern University”. Training involving animal protocols should be tailored according to each protocol and will best be
conducted by the principal investigator of the study with the assistance and cooperation of the Animal Facility consultant
veterinarian. (See also Midwestern University Institutional Animal Care and Use Program, Sec. IIA, par. 3c.)
All individuals will be provided with instruction by their supervisor regarding the nature of hazards they work with and
particular precautions for avoidance or minimizing risks associated with the hazard. In some cases, this may require being
enrolled in Midwestern University’s Respiratory Protection Program. In addition, personnel will be told and encouraged to
report all injuries immediately to their supervisor and the Biosafety Committee Chair.
V.
Personal hygiene
Personal hygienic practices should be tailored according to each protocol, especially with regard to personal and protective
clothing (disposable gloves, masks, head covers, booties, coats, etc.; also see Personal Protective Equipment section below).
A laundering service is available to all staff, faculty, and technical personnel. In addition, the Animal Facility has its own
laundry available on an as needed basis. Hand washing after handling any animals will always be required. Eating,
drinking, use of tobacco products, and cosmetic application will be strictly prohibited. (See also Midwestern University
Institutional Animal Care and Use Program, Sec. IIA, par. 4c.)
VI.
Personal Protective Equipment (PPE)
Animal care personnel should wear their MWU-issued protective clothing, shoes or shoe covers, and gloves whenever
needed. When appropriate, personnel should shower when they leave the animal care or procedure areas of certain animals.
Protective clothing and equipment should not be worn beyond the boundary of the hazardous-agent work area or the animal
facility. Personnel with potential exposure to hazardous agent work areas will be provided with PPE appropriate to the
agents. Hearing protection is provided and required in high-noise areas, such as when operating the bedding dispenser.
Personnel working in areas where they might be exposed to contaminated airborne particulate material or vapors shall be
enrolled in MWU’s Respiratory Protection Program where they will be provided with suitable respiratory protection,
respirator fit testing, and training in the proper use and maintenance of the respirator.
VII.
Facilities, procedures, and monitoring
See Midwestern University Institutional Animal Care and Use Program, Section IIB-C.
VIII.
Animal experimentation involving hazardous materials
All protocols involving nuclear, biological, and chemical hazards must first be approved through the appropriate University
safety committee. Policies for this are already in place (See the Midwestern University Research Safety Manual and
Chemical Hygiene Plan and the Radiation Safety Handbook).