ࡱ>  8bjbjVV 1<<G83.7. g!"A6C6C6C6C6C6C6$\8:g6+#A"c+#+#g66'''+#FA6'+#A6''4| 6\q#v 5-660.75;#;$ 6; 6$+#+#'+#+#+#+#+#g6g6'+#+#+#.7+#+#+#+#;+#+#+#+#+#+#+#+#+# :  INCLUDEPICTURE "http://www.uaa.alaska.edu/marketing/images/59591233.wmf" \* MERGEFORMATINET  Occupational Health and Safety in the Care and Use of Research Animals Medical Questionnaire Instructions: Initial Enrollment and Annual Review: This questionnaire is to be completed only if the review of your Hazard Evaluation Survey has assigned you to an Occupational Health and Safety risk category that requires review of a medical questionnaire by the Universitys contract Health Care Provider. Do not submit this questionnaire unless notified to do so by ¼ϲʿ EH&S. Change of Status: If your health status changes after enrollment but prior to your annual review you may submit this form to the Health Care Provider. Please let ¼ϲʿ EH&S know that you have submitted a medical questionnaire for change of status. This questionnaire provides information to the health care provider so they may offer useful advice and recommendations to ensure that your work environment is safe. This questionnaire is confidential and for review only by the Universitys Health Care Provider. It will be maintained in your medical record and not returned to the university. To ensure a proper medical evaluation the ORI will also provide the Health Care Provider a copy of your Hazard Evaluation Survey. If instructed, please complete this electronic form on your computer and then submit a hard copy to the Contract Health Care Provider specified by ¼ϲʿ EH&S.  INCLUDEPICTURE "http://www.uaa.alaska.edu/marketing/images/59591233.wmf" \* MERGEFORMATINET  Occupational Health and Safety in the Care and Use of Research Animals Medical Questionnaire This is for:  FORMCHECKBOX  Initial Enrollment  FORMCHECKBOX  Change of Status  FORMCHECKBOX  Annual Renewal Name: (Last)  FORMTEXT       (First)  FORMTEXT       (MI)  FORMTEXT    Date: (M/D/YY)  FORMTEXT       SSN:  FORMTEXT       (required field)Sex:  FORMCHECKBOX Male  FORMCHECKBOX FemaleDate of Birth: (M/D/YY)  FORMTEXT       Job Title:  FORMTEXT       Institute/Department:  FORMTEXT       University Mailing Address:  FORMTEXT      Work Phone:  FORMTEXT       Home Phone:  FORMTEXT      Fax:  FORMTEXT      e-mail:  FORMTEXT       Do you have any of the following symptoms that you feel are caused by, or made worse by any environment where you come into contact with animals? Check Yes or No; if yes then indicate the animal involved. SymptomYesNoAnimal involved Watery, burning or itchy eyes  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       Runny nose  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       Sneezing  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       Wheezing  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       Cough  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       Shortness of breath  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       Chest tightness  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       Hives  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       Rash  FORMCHECKBOX   FORMCHECKBOX   FORMTEXT       What, if any, over-the-counter or prescription medications do you take for these symptoms:  FORMTEXT        FORMTEXT        FORMTEXT       Do you have a history of (check Yes or No): YesNoAsthma FORMCHECKBOX  FORMCHECKBOX Hayfever FORMCHECKBOX  FORMCHECKBOX If + for hayfever, is it Spring or Fall? FORMTEXT       Have you ever had a skin test performed to determine what your allergies are, if any? 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FORMTEXT       Are you now, or have you ever been a cigarette smoker (one or more per week)? Yes FORMCHECKBOX  No FORMCHECKBOX  If  yes estimate how many cigarettes/day for how many years: FORMTEXT       What animals are you exposed to away from work?  FORMTEXT       Do you have any allergic symptoms to these pets?Yes FORMCHECKBOX No FORMCHECKBOX  If  yes , what were the symptoms?  FORMTEXT       Have you ever been diagnosed with a disease acquired from animals (zoonosis or other infection)? Yes FORMCHECKBOX  No FORMCHECKBOX  If  yes explain: FORMTEXT       Do you have any health problems that might interfere with your ability to handle animals? Yes FORMCHECKBOX  No FORMCHECKBOX  If  yes explain: FORMTEXT       Are you immunosupressed? Yes FORMCHECKBOX  No FORMCHECKBOX  If  yes specify: FORMTEXT       [e.g. splenectomy, taking steroids, chemotherapy, other] Have you been immunized against tetanus? Yes FORMCHECKBOX  No FORMCHECKBOX  If  yes indicate last vaccination date: FORMTEXT       Have you been immunized against Rabies? Yes FORMCHECKBOX  No FORMCHECKBOX  If  yes indicate last vaccination date: FORMTEXT       Indicate last titer and date obtained: FORMTEXT       Have you ever had a significant exposure to any biohazardous agent, chemical, radiation, or infectious agent? (Significant refers to an exposure requiring first aid or medical attention. This refers to any accidental or uncontrolled exposure.) Yes FORMCHECKBOX  No FORMCHECKBOX  If  yes , describe the exposure(s) and provide the date.  FORMTEXT       Are you pregnant or do you expect to become pregnant in the next 12 months? (Pregnant women need to take extra precautions when working within animal research facilities.) 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