University of Arkansas

Animal Worker Health Screening Questionnaire

In order to comply with the University of Arkansas’ Assurance of Compliance with the US Public Health Service (PHS), Office of Laboratory Animal Welfare, all individuals who engage in research activities, supported by PHS, using live vertebrate animals, or conduct animal research in PHS covered facilities must participate in a safety and health protection program prior to beginning work with animals with renewal every three (3) years, in the event of any major health changes, or at the provider's request. All animal workers must be informed of known health and safety risks, trained in safety protections or practices, and provided with appropriate Personal Protective Equipment (PPE) other than routine laboratory coats/smocks/jackets. Health screening is required when the animal work presents more than minimal risk of allergy/asthma, development/exacerbation of or contracting zoonotic disease (disease capable of being transmitted from animal to human). Individuals for whom health screening is required include those who are involved in the direct care of, or have direct contact with, laboratory rodents or birds that are procured from authorized breeding sources/vendors and wild mammals and birds, whether captured and released in the field or maintained in an animal facility. Faculty, staff and students must complete this screening questionnaire which will be reviewed by a licensed, health care provider from the Pat Walker Health Center (PWHC). Individuals who have a medical history raising concerns with working with animals will be referred to their primary care provider or the Arkansas Occupational Health Clinic located in Springdale; phone number (479) 725-3000.

Instructions: Complete this form and submit it directly to the PWHC, ATTN: AJ Olsen either by fax at (479) 575-8793 or email to pwhc@uark.edu. Once reviewed by a PWHC medical provider, he/she will send you and the IACUC coordinator (iacuc@uark.edu) email confirmation. There is a $40 fee associated with this screening.

THIS FORM CONTAINS CONFIDENTIAL MEDICAL INFORMATION FOR HEALTH CARE PROVIDER USE ONLY.

Animal Worker Name:

University Email Address:

Supervisor’s Name:

Cost Center No. Graduate Student Undergraduate StudentFull-Time Employee Part-Time Employee

Visiting Faculty/Staff

ROLE HISTORY/PROPOSED ROLE:

Indicate the type(s) of animals you do or will handle through your work at UA (check all that apply):

Rats Mice Hamsters Chickens Rabbits Other:

Did you receive instruction regarding species-specific risks and handling information from your

Supervisor?

Do you work outside of UA with non-human primates, with primate tissues, or in an area where

primates or primate tissues are housed and handled?

Do or will you work with other feral (wild) animals or random source (Class B) dogs or cats?

Do or will you work with human blood products or human tissue?

MEDICAL HISTORY:

Have you had any of the following (check all that apply)? Peumonia in the last year

Heart Murmur/Heart Valve Disease

Liver Disease

Seizures/Epilepsy

Recurrent Bronchitis or asthma

Diabetes

Gastrointestinal Disorder

Immune system deficiency

Heart Disease

Kidney Disease

Cancer

Chronic Lung Condition

Yes No

Yes NoYes No

Yes No

University ID No.Date of Birth:

Department: A cost center number is required if the department is covering the $40 screening fee.

Animal Worker Name: University ID No.

MEDICAL HISTORY (Continued):

Yes No Have you ever contracted a disease from animals or experienced any animal related injury (including bites, scratches, needle sticks, etc.)? If yes, please explain:

Yes No Have you been told by a physician that you have an immune compromising medical condition or are you taking medications that may impair your immune system (steroids, immunosuppressive drugs, or chemotherapy)? If yes, please explain:

Yes No Are you currently taking any medications? If yes, list:

Yes No For women: Are you pregnant or planning to become pregnant in the next two years?

ALLERGY HISTORY:

List any allergies to medications:

Do you have any of the following (check all that apply)?

Chronic cough Asthma Hay fever Skin rash

Are you allergic to any of the following (check all that apply)?

Dog Cat Cattle HorseHog Primates Rabbit Goat

Rat or Mouse Guinea Pig Alfalfa Weeds

Grasses Wood Chemicals Latex

Itchy, irritated eyes

Bird/Feathers

Sheep/Wool

Trees

Insect Stings/Bites

Animals at your work site Other:

Animal Worker Name: University ID No.

IMMUNIZATIONS:

Indicate status of vaccination or blood test to document immunity (check only one for each immunization/immunity check):

Measles

Mumps

Rubella

Hepatitis A

Hepatitis B

Rabies

Date of last Tetanus booster:

Date of last PPD (tuberculin) skin test or T-Spot blood test: Negative Positive

If TB test positive, date of last chest x-ray:

If TB test positive in the past, are you having any of the following symptoms (check all that apply)?

Fever Chronic cough Bloody sputum Weight loss Shortness of breath

This section to be read and signed by the ANIMAL WORKER

My signature indicates that the above information is true and accurate to the best of my knowledge.

Animal Worker Signature Printed Name

CMV

Toxoplasmosis

“Q” Fever

Yellow Fever

Smallpox

Tuberculosis (BCG)

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