ࡱ> @C=>?{ bjbjBrBr 4  \-k^ ^ 8\+fL\$$$$ && (&)))))))$,/r*50& & &0&0&*$$4K+'''0&R$$)'0&)'''$Y,x&R')a+0+'0&$0'0'0&0&'0&0&0&0&0&**'0&0&0&+0&0&0&0&00&0&0&0&0&0&0&0&0&^ ~: AV Institutional Animal Care and Use Program Animal Worker Health Screening Questionnaire AV requires all individuals who work with vertebrate animals to participate in a safety and health protection program prior to beginning work with animals. 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). Health screening is required when the animal work presents more than minimal risk of allergy/asthma development/exacerbation or of 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 breeding sources/vendors and wild mammals and birds, whether captured and released in the field or maintained in an animal facility. Non-student employees who do not have pre-existing allergies to animals and who are not immune-compromised may be screened by their regular health care provider. Students who do not have pre-existing allergies to animals and who are not immune-compromised may be screened at no cost at AV Student Health Services. Individuals who do have pre-existing allergies to animals, asthma, or may be immunocompromised (e.g., have HIV/AIDS, are receiving chemotherapy, are taking steroids or immunosuppressive drugs) must be screened by an occupational health professional. South Georgia Medical Center operates an Occupational & Industrial Medicine Center at 520 Griffin Avenue, Valdosta (229-249-4010). INSTRUCTONS: 1. Please call your regular health care provider or, as appropriate, an occupational health professional, to schedule a health screening appointment. Students may contact Student Health Services (229-333-5886) to be screened at no cost; be sure to mention that you need an Animal Worker Health Screening. 2. Complete this form and take it, along with a copy of the completed Animal Worker Occupational Safety and Health Information form, to your appointment. THIS FORM CONTAINS CONFIDENTIAL MEDICAL INFORMATION FOR HEALTH CARE PROVIDER USE ONLY. Do not give this form to your Supervisor or anyone else at AV.  Animal Worker Name:  FORMTEXT      ID (870) No:  FORMTEXT       Dept:  FORMTEXT      Supervisor:  FORMTEXT       FORMCHECKBOX  Full-Time Employee FORMCHECKBOX  Part-Time Employee FORMCHECKBOX  Grad Student FORMCHECKBOX  Undergrad Student ROLE HISTORY/PROPOSED ROLE:Indicate the type(s) of animals you do or will handle through your work at AV (check all that apply): FORMCHECKBOX  Lab Mouse FORMCHECKBOX  Lab Rat FORMCHECKBOX  Lab Hamster FORMCHECKBOX  Lab Guinea Pig FORMCHECKBOX  Lab Gerbil FORMCHECKBOX  Lab Rabbit FORMCHECKBOX  Other Lab Mammal (Species:  FORMTEXT      ) FORMCHECKBOX  Breeder-Supplied Bird (Species:  FORMTEXT      ) FORMCHECKBOX  Vole/Chipmunk FORMCHECKBOX  Wild Mammal (Species:  FORMTEXT      ) FORMCHECKBOX  Wild Bird (Species:  FORMTEXT      ) FORMCHECKBOX  Yes  FORMCHECKBOX  NoDid you receive instruction regarding species-specific risks and handling information from your Supervisor?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDo you work outside of AV with non-human primates, with primate tissues, or in an area where primates or primate tissues are housed and handled? FORMCHECKBOX  Yes  FORMCHECKBOX  NoDo or will you work with other feral (wild) animals or random source (Class B) dogs or cats? FORMCHECKBOX  Yes  FORMCHECKBOX  NoDo or will you work with human blood products or human tissue? MEDICAL HISTORY:Have you had any of the following (check all that apply)? FORMCHECKBOX  Pneumonia FORMCHECKBOX  Recurrent Bronchitis FORMCHECKBOX  Tuberculosis FORMCHECKBOX  Heart Disease FORMCHECKBOX  Rheumatic Fever FORMCHECKBOX  Heart Murmur/Heart Valve Disease FORMCHECKBOX  Diabetes FORMCHECKBOX  Kidney Disease FORMCHECKBOX  Liver Disease FORMCHECKBOX  Cancer FORMCHECKBOX  Gastrointestinal Disorder FORMCHECKBOX  Loss of Consciousness FORMCHECKBOX  Seizures FORMCHECKBOX  Arthritis FORMCHECKBOX  Chronic Back or Joint Pain FORMCHECKBOX  Cystic Fibrosis FORMCHECKBOX  Emphysema or Chronic Lung Condition FORMCHECKBOX  Yes  FORMCHECKBOX  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:  FORMTEXT       Animal Worker Name:  FORMTEXT      ID (870) No.  FORMTEXT      MEDICAL HISTORY (Continued): FORMCHECKBOX  Yes  FORMCHECKBOX  NoHave 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:  FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  NoAre you currently taking any medications? If yes, list:  FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  NoFor women: Are you pregnant or planning to become pregnant in the next two years?  ALLERGY HISTORY:List any allergies to medications:  FORMTEXT      Do you have any of the following (check all that apply)? FORMCHECKBOX  Chronic cough FORMCHECKBOX  Asthma FORMCHECKBOX  Hay fever FORMCHECKBOX  Skin rash FORMCHECKBOX  Itchy, irritated eyesAre you allergic to any of the following (check all that apply)? FORMCHECKBOX  Dog FORMCHECKBOX  Cat FORMCHECKBOX  Cattle FORMCHECKBOX  Horse FORMCHECKBOX  Bird/Feathers FORMCHECKBOX  Hog FORMCHECKBOX  Primates  FORMCHECKBOX  Rabbit  FORMCHECKBOX  Goat  FORMCHECKBOX  Sheep/Wool  FORMCHECKBOX  Rat or Mouse FORMCHECKBOX  Guinea Pig  FORMCHECKBOX  Alfalfa FORMCHECKBOX  Weeds  FORMCHECKBOX  Trees  FORMCHECKBOX  Grasses FORMCHECKBOX  Wood  FORMCHECKBOX  Chemicals  FORMCHECKBOX  Latex  FORMCHECKBOX  Insect Stings/Bites  FORMCHECKBOX  Animals at your work site FORMCHECKBOX  Other:  FORMTEXT       IMMUNIZATIONS:Indicate status of vaccination or blood test to document immunity (check only one for each immunization/immunity check): Measles FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureMumps FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureRubella FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureHepatitis A FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureHepatitis B FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureRabies FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureCMV FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureToxoplasmosis FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  Unsure Q Fever FORMCHECKBOX  Had - Date:  FORMDqr  1 8 ? 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laytIG444444444444.50525N5P5R5T5l5n5p55ȱȞlbNb'jihshIGCJPJUaJhIGCJPJaJ'jhhshIGCJPJUaJ!jhshIGCJPJUaJhshIGCJPJaJ$jhw_HhIG>*CJPJUaJ,hIG>*CJOJPJQJ^JaJmHnHu;jhw_HhIG>*CJOJPJQJU^JaJmHnHu2hw_HhIG>*CJOJPJQJ^JaJmHnHuV4405n55$&`#$/IfgdIG5555555555555555556( ( (((͸ͤÙxvx`B;jhw_HhIG>*CJOJPJQJU^JaJmHnHu*jkhw_HhIG>*CJPJUaJUhw_HhIG>*CJPJaJ$jhw_HhIG>*CJPJUaJhIG6CJPJaJ'jjhshIGCJPJUaJhshIGCJaJhIGCJPJaJhshIGCJPJaJ!jhshIGCJPJUaJ'jnihshIGCJPJUaJ5555.$&`#$/IfgdIGkdi$$Iflֈ~ &+    t 6`0644 laytIGTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureYellow Fever FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureSmallpox  FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureTuberculosis (BCG) FORMCHECKBOX  Had - Date:  FORMTEXT       FORMCHECKBOX  Had but do not recall date FORMCHECKBOX  Have not had FORMCHECKBOX  UnsureDate of last Tetanus booster:  FORMTEXT     _________ Date of last PPD (tuberculin) skin test:  FORMTEXT     _________  FORMCHECKBOX  Negative  FORMCHECKBOX  PositiveIf PPD POSITIVE, date of last chest x-ray:  FORMTEXT     _______  If PPD POSITIVE in the past, are you having any of the following symptoms (check all that apply)? FORMCHECKBOX  Fever FORMCHECKBOX  Chronic cough FORMCHECKBOX  Bloody sputum FORMCHECKBOX  Weight loss FORMCHECKBOX  Shortness of breath This section to be read and signed by the ANIMAL WORKERMy signature indicates that the above information is true and accurate to the best of my knowledge. Animal Worker SignaturePrinted NameDate Please bring this form, along with a copy of the completed Animal Worker Occupational Safety and Health Information Form, to your health screening appointment. This Certification page should be completed by the health care provider and returned by the Animal Worker to the Institutional Animal Care & Use Committee (IACUC) through the AV Office of Sponsored Programs & Research Administration (OSPRA). Animal Worker Name:  FORMTEXT      ID (870) No.  FORMTEXT       ANIMAL WORKER HEALTH SCREENING CERTIFICATION The above-named individual received a health screening on (date) ____________________.He/she has been immunized against Tetanus within the last ten (10) years and will remain current for at least the next twelve (12) months.He/she has been additionally immunized for the purpose of work with animals against (specify): __________________________. If this individual has been determined to be at more than minimal risk of health consequences of working with animals, he/she has been counseled and advised by a physician regarding those risks.If applicable, this individual has been advised of the need for additional clinical visit(s).  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Printed Name: ________________________________________ Title: ________________________________________________ Address: (If other than AV Student Health Services) __________________________________________ __________________________________________ __________________________________________ Telephone: ________________________________  Please return this Health Screening Certification form (one page only) to: Research Compliance Specialist Office of Sponsored Programs & Research Administration (OSPRA) Psychology Building, Suite 3100 AV NOTE: This certification form must be received by OSPRA before work with animals begins.     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