Occupational Health Program for Personnel with

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MEDICAL IN CONFIDENCE
Appendix A
NUS ANIMAL WORK HEALTH QUESTIONNAIRE
Full Name
Title
Department/Institution
Staff/Student/Attached – pls
circle
Staff/Student Matriculation No
NUS Email
NRIC/FIN
Date of Birth
Supervisor/PI Name and
Contact Number
Home Address
Contact Number
Work:
HP:
Allergies – DRUG/FOOD or
others
A: OCCUPATIONAL RISK FACTORS
1. LABORATORY ANIMAL USE
 I am no longer active on an approved animal use protocol, and will not be working in areas where animals
are housed or transported. (If checked, stop here and return this page).
 I am on an approved animal use protocol, but will not be handling animals, animal tissues or cell lines, or
working in areas where animals are housed or transported. (If checked, stop here and return this page).




I am on an approved animal use protocol and working with animals.
I am not handling animals, but will be working in areas where animals are housed, or transported.
I will be involved with veterinary care or animal husbandry.
I am working with human specimens (cells, body fluids, etc.) in conjunction with animal studies.
 I work in ABSL 3 or BSL 3 Facility.
Animals/tissues/fluids used or
handled














Rodents (eg mice, rats, guinea
pigs)
Wild rodents
Rabbits
Dogs
Cats
Birds
Marine mammals
Reptiles
Fish
Goats
Pigs
Sheep male female
Tree shrews
Non-human primates
 Macaque or its tissues
 Others (specifiy):

Others (specify):

Human specimens (cells, blood,
body fluids)
Daily
Frequency of Contact
1-3 times/wk
1-3
times/month
Infrequent
1-6
times/year
2. PROVIDE THE FOLLOWING FOR EACH AGENT YOUR ARE EXPOSED TO IN CONJUNCTION
WITH ANIMAL STUDIES
Yes
No
If Yes, specify which agent(s).
a. Infectious Agents/r-DNA Technologies


____________________________
b. Chemical Carcinogens


____________________________
c. Radiation


____________________________
MEDICAL IN CONFIDENCE
d.
e.
f.
Anti-Neoplastic/Chemotherapy Agents
Known Reproductive Hazards/Teratogens
Others:






____________________________
____________________________
____________________________
B: PERSONAL HEALTH HISTORY
I. DO YOU HAVE A KNOWN HISTORY OF ANY OF THE CONDITIONS?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Work or animal-related injury or illness in past 12 months?
Tuberculosis or close contact with tuberculosis patient?
Chronic disorder of blood cells
Diabetes mellitus
Autoimmune disease eg lupus, rheumatoid arthritis
Cancer
Chronic viral infection eg HIV, Hepatitis B or C
Congenital conditions resulting in immunodeficiency
Long term steroid treatment for any condition
Chronic lung condition resulting in reduced lung function eg asthma
Environmental or latex allergies?
Are you currently pregnant or pregnancy in the next year?
Please elaborate any ‘Yes’ answers:
Have you been vaccinated against the following?
Tetanus
□ Yes
Hepatitis B
□ Yes
Hepatitis A
□ Yes
BCG (Bacille Calmette-Guerin for TB)
□ Yes
Hepatitis B screen
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
Vaccination dates
□ No
□ No
□ No
□ No
□ No
If Yes –
Hep Bs Antigen: Non-reactive/Reactive
Hep Bs Antibody: unit
Other past vaccinations – please
specify:
II. ENVIRONMENTAL ALLERGIES/ASTHMA
1. Are you allergic to any animal(s)? .......................................................
If yes, list the animals that caused your allergy symptoms ________
______________________________________________________


Don’t
Know

2. Do you have any other known allergies? .............................................
If yes, list cause(s) of allergies: _____________________________
______________________________________________________



3. List symptoms that occur when you are suffering from your allergies:
______________________________________________________
______________________________________________________



4. List treatment that you receive to relieve your allergies: ___________
______________________________________________________



5. Do you have asthma? ..........................................................................
If yes, list cause(s) of asthma (if you do not know, write “UNKNOWN”)
______________________________________________________






7. Do you have any skin problems related to work (e.g., reactions to latex gloves;
Dry cracked skin; rashes)? ..................................................................





Yes
6. Do you currently have allergy symptoms or asthma specifically related to
animals that you currently work with? ..................................................
..............................................................................................................
If yes, list symptoms: _____________________________________
No
If yes, describe: _________________________________________
______________________________________________________
8. Do you experience shortness of breath at work? .................................
If yes, explain: ___________________________________________
______________________________________________________

MEDICAL IN CONFIDENCE
9. Do you wear a fit tested respirator to perform activities at work? ........
If yes: date of last fit testing ________________________________



III. FOR INDIVIDUALS WORING WITH NON-HUMAN PRIMATES
1. Have you had naturally-acquired measles (rubella)? ...........................
2. Have you had measles immunization? ................................................
If yes, approximate date of vaccination(s) _____________________
3. Tuberculosis Surveillance
a. Have you ever lived in countries other than Singapore? .................
If yes, list countries: ______________________________________
b. Have you had active tuberculosis? .................................................
If yes, list year and description of treatment .....................................
c. Date of BCG vaccination: ________________________________
d. Date of last tuberculosis skin test: _________________________
e. Results of TB skin test  Positive
 Negative
f. Date of last chest X-ray: _________________________________
Yes


No






I have answered the questions on this form truthfully and to the best of my recollection.
________________________________
Name/NRIC/Signature
____________________
Date
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