Terry Blasdel, D.V.M. Director, Animal Care Operations
Occupational Safety and Health Program for Animal Users
Participation in the Animal Care and Use Occupational Health and Safety Program is required for personnel who are at risk because of contact with animals. This program has been approved by the University of Houston, Clear Lake, Institutional Animal Care and Use Committee and by Susan Prihoda, Director, UHCL Health and Disability Services. All personnel who have any contact with laboratory animals are encouraged to participate in the risk assessment of this program by answering the attached animal handler’s questionnaire Risk assessment is accomplished through the use of the attached Health Surveillance Questionnaire. On an annual basis you will be asked to update your information which you may do by resubmitting the questionnaire or by answering that there has been no change. All information is confidential and the questionnaires are kept at the Health Center on the UHCL campus. You may refuse to answer the questionnaire, but you are encouraged to read it carefully to assess your risks. All university animal users, including students, are responsible for assuring that they are in compliance with the program.
THIS FORM MUST BE RETURNED TO THE ANIMAL FACILITY OR TEACHER FOR DOCUMENTATION THAT YOU HAVE BEEN INFORMED OF THE INHERENT RISKS OF RODENT EXPOSURE.
Required of all personnel with rodent contact: ____ I will schedule an Animal Handler’s Physical exam and am submitting the Health Surveillance
Questionnaire to the UHCL Health Center, Susan Prihoda, SSCB 1.301, 281-283-2626.
____ I decline to have a physical examination but am submitting the Health Surveillance Questionnaire to the
____ I have read the Health Surveillance Questionnaire and decline to submit it to the UHCL Health Center. ____ I have filled out the Health Surveillance Questionnaire in the past and have reviewed it this year. I have
submitted that there have been no changes to the UHCL Health Center.
Optional but recommended: ____ I am going to the UHCL Health Center for a tuberculin skin test. I will submit the results to the UHCL
____ I am going to my physician for a tuberculin skin test. I will submit the results to the UHCL Health
Personnel and students with a history of allergies are strongly encouraged to fill out the questionnaire and talk to Susan Prihoda about their medical history. If you decline to submit the questionnaire, please initial that you have read the following statements. ____ I understand that rodents can cause allergies in humans. ____ I understand that the allergic reaction can be life threatening in individuals who are sensitive to other
____ I understand that the use of proper personal protective equipment, such as a gown, mask and gloves,
will help protect me from exposure to rodent allergens and that these will be provided to me when I handle rodents.
____ I understand that latex can also cause allergies. If I am allergic to latex, I will request nitrile gloves to
____ I understand that rodents may bite and that a tetanus vaccination within the last 5-10 years is
recommended. Injuries from rodent bites should be reported to my supervisor or teacher.
Health Surveillance Questionnaire for Animal Contact and Use or Significant Biological Agents UHCL Health and Disabilities Service Center Houston, TX 77058-0300 281-283-2629 Confidential Medical Information
PURPOSE: The purpose of this form is to obtain individual health history for an employee working with animals and other significant biological agents. It will be used to evaluate appropriate medical surveillance needs. CONFIDENTIALITY STATEMENT: This form requires that you provide personal health information that is protected by University policy and State and Federal law. Your rights to the confidentiality of your personal health information will be strictly maintained by Employee Health Services. Your information will be used or disclosed in accordance with those policies and laws only to the minimal extent necessary for your treatment or business operations. You have the option of sending the form via regular mail or sending it via interoffice mail to the address above.
INSTRUCTIONS: Please complete entire form. Answers left blank will be assumed to be a negative response. The information you supply will be submitted to the UHCL Health Center medical staff for review. If you have any questions on the form, please contact Susan Prihoda at UHCL Health Center telephone 281-283-2629.
Last Name:________________________________ First Name: _______________________
Department:_______________________________ Job Title:__________________________
Have you had a previous animal handler questionnaire, medical surveillance, or vaccination at UHCL Health Center?
Please indicate what vaccines you have had. If you know the date, please provide.
Vaccine Yes No Date Vaccine Yes No Date
Hepatitis B Series □ □ __________ Rabies titer □ □ __________
Hepatitis A Series □ □ __________ MMR □ □ __________
Measles □ □ __________ Tetanus □ □ __________
Rabies □ □ __________ Oral Typhoid □ □ __________
Vaccinia □ □ __________ Qfever titer
Have you had a PPD (TB) Skin test? Yes□ No□
Date of last PPD skin test. ____________ Result: □ Positive □ Negative
If POSITIVE, date of last chest X-ray _________
If POSITIVE in the past, please indicate Yes/No for each of the following.
Bloody Sputum □ □ Shortness of Breath □ □
Have you had a Tuberculosis (BCG) vaccine? Yes □ No □
Date(s) you had a Tuberculosis (BCG) vaccine___________
Place of birth ___________________________________
Animal / Biological Agent Contact
Please indicate the animals you work with (Check the box if you work with the specified animal). Amphibians
Please indicate tissue, blood, or biological agents that you work with (check the box if you work with the specified product).
Do you work with primate tissues? Yes□ No□ Do you work in an area where primates or primate tissues are housed or handled? Yes□ No□
Do you work with human blood products? Yes□ No□ Do you work with animal blood products? Yes□ No□ Do you work with human tissue? Yes □ No □ Do you work with animal tissue? Yes □ No □ Do you work with recombinant DNA technology? Yes □ No □ If yes, does the research involve techniques in which viable, recombinant DNA-containing micro-organisms are used to infect animals that then require Bio-safety level 3 containment? Yes □ No □
Have you had a prior history of the following conditions? Yes □ No □
If yes, please indicate the condition(s), and enter the date of onset (if known).
Condition Condition Yes Date
Pneumonia □ _________ Recurrent Bronchitis □ ________
Tuberculosis □ _________ Heart Disease □ ________
Rheumatic Fever □ _________ Heart Murmur or Valve Disease □ _________
Diabetes □ _________ Kidney Disease □ _________
Liver Disease □ _________ Cancer □ _________
Gastrointestional Disorders □ _________ Loss of Consciousness □ _________
Seizures □ _________ Arthritis □ ________
Chronic Back or Joint Pain □ _________
Have you been told by a physician that you have an immune compromising medical condition or are you taking medications that impair your immune system (steroids, immunosuppressive drugs, or chemotherapy)? Yes □ No □
Are you currently taking any medications (Including non-prescription)? Yes □ No □ If yes, list below: ________________________________________________________
For Women: Are you pregnant, or planning to be pregnant in the next year? Yes □ No □
Animal Related Injuries or Illnesses
Have you ever contracted a disease from animals, or experienced an animal related injury (including bites, scratches, needle sticks, etc.)? If yes, please indicate the last 5 occurrences. Date _____________ Injury/Illness _______________Treatment Location________________ Date _____________ Injury/Illness _______________Treatment Location________________ Date _____________ Injury/Illness _______________Treatment Location________________ Date _____________ Injury/Illness _______________Treatment Location________________ Date _____________ Injury/Illness _______________Treatment Location________________
Have you had any recent problems with the following symptoms? Yes □ No □
Please indicate which symptoms you have experienced (check the yes or no box next to each symptom).
Chronic allergies (dust, pollen, food, mold)
Are these more frequent while at work? Yes □ No □
Dogs □ Cats □ Cattle □ Horses □ Bird (Feathers) □
Pigs□ Primates □ Rabbits □ Goats □ Sheep (Wool) □
Rats or Mice □ Guinea Pig □ Alfalfa □ Weeds □ Trees □
Chemicals □ Latex □ Wood □ Grasses □ Mold
Other □ List: ____________________________________________________________
Have these required any treatment with over-the counter medications (Claritin, Benadryl, decongestants, eye drops, etc?) Yes □ No □
Have you had to wear a respirator, goggles or protective clothing to protect yourself from allergies (e.g., hay fever [rhinitis], eye symptoms, hives or asthma) at work? Yes □ No □
Have you been treated by your own physician for allergies that began at work? Yes □ No □
Has you health status changed in the last year? □ No. □ Yes, please explain: ____________.
If you suspect you may have work related allergies or have any other questions about your health status or this form, please contact:
Susan Prihoda Director, Health and Disabilty Services SSCB S1301 UHCL Health Center Houston, TX 77058-0300 281-283-2629
ADDITIONAL INFORMATION: For detailed information on animal allergies and other hazards, please request a copy of “Allergies in Animal Handlers” and “General Hazards Working with Lab Animals” from Roberta Hohmann at 281-283-3015.
This information will now be evaluated and if further action is required, you will be contacted by UHCL Health Center medical staff for additional information, action and training.
MEDICATIONS, VITAMINS AND SUPPLEMENTS TO AVOID Your safety in surgery requires that you disclose al medications, vitamins and supplements that you regularly take. In the ( ) days prior to surgery, you wil be required to stop taking certain medications, vitamins and supplements, both those you regularly take, and those that may be taken incidental y for pain or other symptoms. ) M.D.
Smoking was an exclusion criterion for controls, whereasFigure 1. Methodological Quality of Animal Trials (n=76)4 of the 21 cases were regular smokers of 2 to 10 cigarettesper day. Mean urinary excretion rates of 8-iso-PGF2␣ weresimilar in the 4 smokers (404 pg/mg of creatinine) and inthe 21 cases considered as a whole (482 pg/mg of creati-nine). Urine albumin excretion rates were not teste