Attachment_9.doc

Laboratory Animal Allergy Questionnaire

Date________________________

Name:___________________________________________

Supervisor:_______________________________________

Department:______________________________________________________________

Age:___________ Sex: ___Male ___Female

OCCUPATIONAL HISTORY

Answer these questions about your present job:

Job title:______________________________________________________

Number of years employed at this facility:________

How many months/years at your present position?______

Brief description of duties ____________________________________________________________________________________________________________________________________________________________________________

Do you work with laboratory animals? ___Yes ___No

If yes, complete the following.

Animal

Yes No Approximate Contact Hours/Day

Rats

Mice

Rabbits

Guinea Pigs

Other

Do you feel that you are allergic to any of these animals? ___ Yes ___ No

___ Rats ___ Mice ___ Rabbits ___ Dogs ___ Other

___ Cats ___ Monkeys ___ Cattle ___ Guinea Pigs

Did you work with laboratory animals before your employment at this facility?

___ Yes ___ No

If yes, how long?_____ years What type of animals? ______________________

Do you use or wear any of the following items when working with animals?

Protective Eye Glasses ___ Yes ___ No

Mask/Respirator

___ Yes ___ No

Lab Coat

___ Yes ___ No

Gloves

HOME ENVIRONMENT INFORMATION

Do you have any indoor pets? ___ Yes ___ No If yes, which animals and for how long?

Animal

1-2 Years 2-3 Years 3-4 Years Over 4 Years

Dogs

Cats

Other (Type)__________

Do you regularly have any of the following symptoms? ___ Yes ___ No Please indicate if the symptom is present and the year of onset. Also check in what location or time “period” the symptom(s) is/are present.

Yes/No Year of

Symptoms Are Present

Symptom

Present Onset

At Work At Home On Vacation No Difference

Cough

Sputum Production

Shortness of Breath

Wheezing

Chest Tightness

Asthma

Nose Congestion

Runny Nose

Sneezing

Itchy Eyes

Sinus Problems

Hay Fever

Frequent Colds

Hives

Skin Rash

Swelling of Eyes or Lips

Eczema

Difficulty in Swallowing

Were you ever told by a doctor that you had allergies? ___ Yes ___ No

Have you ever been skin tested for allergies? ___ Yes ___ No If yes, what substances were you found to be allergic to or sensitized to?

___ Ragweed ___ Grass ___ Trees ___ Mold ___ Dust ___ Cat ___ Dog ___ Mice ___ Other _____________________________________________________________

Have you ever received allergy (desensitization/immunotherapy) shots? ___ Yes ___ No

Has a doctor ever said you have asthma? ___ Yes ___ No

If yes, when did your asthma start? __________ (year)

Are you currently taking medication (either over the counter or by prescription) to control your asthma?

Has a doctor ever told you that you have a medical condition caused by your working conditions?

Do any of your blood relatives (grandparents, parents, brothers/sisters) have allergies or asthma?

Are you under a doctors care for any other illnesses?

If yes, please list illnesses: ______________________________________________________________________________________

Do you take blood pressure medication(s)? ___ Yes ___ No

Do you regularly use “over the counter” (nonprescription) nose drops or nose sprays (e.g., Afrin, Neosynephrine)? ___ Yes ___ No

Do you smoke cigarettes? ___ Yes ___ No If yes, how many cigarettes per day?________

How many years?_______

If not presently smoking, did you ever smoke? ___ Yes ___ No

If yes, when did you stop smoking cigarettes? _________ (year)

How many years did you smoke? __________ years

Comments

Medical recommendation

Employee

□ The employee is cleared for contact with the research animals.

□ The employee is cleared for contact with the research animals with the following restrictions:

□ The employee is not cleared for contact with the research animals.

Reviewed By:______________________________________ Date:___________________