CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA
Environmental Health and Safety
CONFIDENTIAL HEALTH HISTORY QUESTIONNAIRE (HHQ)
FOR
STUDENTS, FACULTY, STAFF & ALL OTHERS
EXPOSED TO LABORATORY ANIMALS
Information provided in this questionnaire may become a part of your CONFIDENTIAL medical records
maintained by the Student Health Services. Completion of this questionnaire is a requirement for working with
animals on specific protocols designated by the Cal Poly Pomona Animal Care and Use Committee.
Identification
Last Name
Date of Birth
First
Middle
(MM/DD/YY)
Male

Female 
Bronco/Employee Number
Animal Use Protocol(s) and Principle Investigator or Course Code, Section and Faculty member for
which authorization is requested
(Indicate Protocol Number or Course Code & Responsible Faculty Member):
Locations where you will be working with animals
(Please provide building, room number & phone extension if working on campus.)
Where can you be contacted?
Campus Address
Permanent Address
Room/Bldg
Department
Apt#
Extension
City
E-mail
Phone (
Zip
)
Current Employment/Academic Status (check all that apply):
Undergraduate Student .............. 
Faculty ........................................ 
Animal Handler ........................... 
Staff ............................................ 
Graduate Student................................................
Research Technician/Associate .........................
Volunteer .............................................................
Other
........................
Which animals/organisms will you have contact with? (Consult with Responsible Faculty
Member and Check all that apply.)

Rats,  mice,  rabbits,  guinea pigs,  hamsters,  gerbils,  birds, and  swine.
These animals present a mild risk of injury (primarily bites and scratches), zoonotic disease, but
significant potential for allergies. [These organisms pose a MILD risk to your health unless your immune
system is compromised in which case the risk will be more severe.]

Dogs,  cats,  sheep,  cattle,  goats,  horses, and  wild rodents,
These animals present a moderate risk of injury (primarily bites, scratches, kicks, and crushing),
zoonotic diseases (rabies, Q fever, Hanta virus, bacterial and fungal infections), and significant potential
for allergies. [These organisms pose a MODERATE risk to your health unless your immune system is
compromised in which case the risk will be more severe.]

Class 1 Pathogens (bacterial, viral, or fungal agents not known to cause disease in healthy adult
individuals). [These organisms pose a MINIMAL risk to your health unless your immune system is
compromised in which case the risk will be more severe.]

Amphibians, fish or reptiles or Class 1 Pathogens (bacterial, viral, or fungal infections requiring
Biosafety Level 1). [These organisms pose a LOW risk to your health unless your immune system is
compromised in which case the risk will be more severe.]

Class 2 Pathogens (bacterial, viral, or fungal infections requiring Biosafety Level 2). [These organisms
pose a MARKED risk to your health unless your immune system is compromised in which case the risk
will be more severe.]
IF YOUR IMMUNE SYSTEM IS COMPROMISED BY DISEASE (e.g. Hodgkins, Cancer, HIV, or AIDS), OR
DRUGS (e.g. anticancer drugs, chronic oral doses of prednisone or cortisone). YOU SHOULD SEEK THE
ADVICE OF YOUR PHYSICIAN BEFORE CONTINUING THIS EXPOSURE. LIKEWISE, WORKING WITH
ANIMALS CAN BE A RISK DURING PREGNANCY. CONSULT YOUR PHYSICIAN PRIOR TO WORKING
WITH ANIMALS IF YOU ARE, OR INTEND TO BECOME, PREGNANT.
Are you pregnant or planning to get pregnant (response is optional)? NO 
Does working with animals cause you any of the symptoms below?
(Check all that apply.)
Watery, burning, or itchy eyes ......
Wheezing ................................................
Nasal dripping ..............................
Cough .....................................................
Sneezing ......................................
Shortness of breath .................................
Rash .............................................
Chest tightness .......................................
Hives ............................................
Specify Animal(s) & Severity
Have you ever been diagnosed with any of the following? (Check all that apply.)
Asthma .........................................
Allergic Conjunctivitis ..............................
Allergic Rhinitis .............................
Lung Problems ........................................
Sickle Cell Anemia .......................
Spleen Problems/Absence of Spleen ......
Serious Renal or Liver Disease ....
Chronic Health Issues (e.g. Diabetes) ....
Have you ever had any of the following? (Check all that apply.)
Heart valve disease or heart birth defect ................................................ 
Prescription drugs or therapies that suppress your immune system ...... 
Specify
An immune deficiency ............................................................................ 
Allergy to latex products ......................................................................... 
Infection acquired from an animal .......................................................... 
YES 
Animal allergy of any kind ...................................................................... 
Specify Severity of Allergic Response and Animal
Does the work covered by the relevant protocol include any work with human blood, body
fluids or tissue?
NO 
YES  If yes, describe
Have you recently been exposed to anyone who is?
Infected with tuberculosis ..................................................... NO
Infected with measles ........................................................... NO


YES
YES


If this is a renewal of your Health History Questionnaire, please indicate which of the
responses above that relate to your health status are different from the last time you
completed this form.
If this is a renewal of your Health History Questionnaire, since you last filed this form,
have you had any of the following while working in a Cal Poly laboratory facility?
Bites by laboratory animals ........................................................... 
Scratches by laboratory animals ................................................... 
Muscle sprain or injury .................................................................. 
Needle stick or scalpel injury ......................................................... 
Cut received from animal cage or equipment ................................ 
# of times
# of times
# of times
# of times
# of times
If you have not had a tetanus vaccination [Given as Tdap (tetanus, diphtheria, and
acellular pertussis (whooping cough)] within the last ten (10) years you are strongly
encouraged to receive one at your earliest convenience. Other Vaccinations are
recommended if you will be exposed to a disease for which the CDC recommends a
vaccination (e.g. Rabies for individuals working with wild bats).
Signature
Date
PLEASE MAKE AN APPOINTMENT TO SEE DR. STEVEN DESTEFANO in Student Health Services, and
TAKE THIS COMPLETED FORM WITH YOU. Contact Student Health Services at 909-869-4000 to make an
appointment at your earliest convenience. When scheduling the appointment indicate that you wish to see Dr.
DeStefano regarding your "Animal Handler Questionnaire". Failing to complete the HHQ process could affect
your ability to participate in class activities or gain access to animal facilities. For questions, please call David L.
Patterson at extension 3695
For Physician Use Only
Reviewed by
Work/exposure to animals is NOT RECOMMENDED:
Comments (if any):
Date

Revised 11/22/2013