To:

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? Vaccines:
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 Tuberculosis Testing
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 ___________________________________ Primary Language________________________________ 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 □ Medical History
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________________ Animal Allergies
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). Condition
Condition
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.

Source: http://coursesite.uhcl.edu/hsh/ward/training/0_ALL_Cover%20Sheet_Health%20Surveillance%20Questionnaire_UHCL_FINAL%207.2007.pdf