Attachment 4 - Baseline Quesionnaire Animal Laboratory PDF.pdf

Animal Exposure Baseline History

Employee Occupational Health VA Puget Sound Health Care System

1660 S Columbian Way S-111-EMP, Seattle WA 98108

(206)-277-3575

1. Name: __________________________ Social Security Number (Last 4): _________

2. Date of Birth: ___________________ Male Female Pregnant?

3. Service: _______________________ Job Title: ______________________________

4. Extension: ________ Pager: _____________ E-mail: _________________________

5. Routing Symbol: ____________ Building and Room #: _________________________

6. Supervisor’s Name: _______________________ Phone: ______________________

7. Animal contact within VA Medical Center (check all that apply):

Dogs Swine Mice Cats

Sheep Hamsters Nonhuman Primates

Goats Gerbils Rabbits Guinea Pigs

Rats Other: _______________________________

8. Have you ever contracted a disease from animals, or experienced an animal-related injury (including bites, scratches, needle sticks, etc.)? Yes No

If yes, please describe:

9. Please check all of the activities that apply:

Direct hands-on work with animals

Work with unfixed animal tissues/fluids

No direct contact, enter animal facility but do not enter animal holding rooms

No direct contact, but enter animal holding rooms

No direct contact, but work on ventilation system, including changing filters

10. Total amount of contact time with animals (include contact with animal tissues, waste, body fluids, carcasses, or animal quarters):

More than one hour/week

One or less hour/week

Other (explain): ______________________________________________

11. Does your work with animals involve any human or animal pathogens or infectious diseases?

Yes No

If yes, please list pathogens or diseases: _____________________________

1660 S Columbian Way S-111-EMP, Seattle WA 98108

(206) 277-3575

12. If you are in contact with nonhuman primates:

a. Have you ever had tuberculosis (TB)? Yes No

If yes, please list medications and how long you took them: _________________

b. Have you been immunized with Bacillus Calmette-Guerin (BCG) for TB?

Yes No Year: ______

c. Have you ever had a positive reaction to a TB test (Tine Test, PPD, Tuberculin Skin Test)? Yes No

If yes, please name any medications you took and the length of time you took them.

13. Are you receiving immunosuppressive therapy such as prednisone, steroids, or anti-cancer drugs? Yes No

14. How often do you wear personal protective equipment when working with animals?

(Check the appropriate responses.)

Type of PPE Sometimes Always Never Rarely

Gloves

Gown

Mask

Cap

Goggles/Glasses

15. Do you smoke, eat, or drink in the animal areas? Yes No

16. How often do you do the following after handling animals at work?

Sometimes Always Never Rarely

Wash Hands

Change Clothing

Shower

17. Do you have a history of the following conditions? (Check those you have or have had.)

Hay fever Asthma Allergic Skin Problems Eczema

Sinusitis Other Chronic Respiratory Infections

18. Has anyone in your family ever had hay fever, asthma, eczema, or allergic skin problems?

Yes No

Not Applicable (skip to question #13)

1660 S Columbian Way S-111-EMP, Seattle WA 98108

(206) 277-3575

Yes No

19. Do you have sneezing spells, runny or stuffy nose, watery or itchy eyes, coughing, wheezing, or shortness of breath, skin rash or hives, or difficulty swallowing after working with laboratory animals or their cages?

(Circle those above you have.)

20. Which animals cause the above problems?

21. How frequently are you bothered by the symptoms below?

Symptoms Never Monthly Weekly Daily

Watery, itchy eyes

Runny or stuffy nose

Sneezing spells

Frequent, dry cough

Wheezing in chest

Rash or hives

Shortness of breath

Trouble swallowing

22. Do you have any house pets? Yes No

If yes, what type of animals do you have? _______________________________

23. Do you have any symptoms with your pets? Yes No

If yes, what type of symptoms do you have? _____________________________

24. Do you have a chronic respiratory disease? Yes No

If yes, please explain: _____________________________________________

25. Have you ever had a hernia (rupture)? Yes No

If yes, please explain: _____________________________________________

26. Have you ever had back trouble or pain that required treatment, surgery, or loss of time at work? Yes No

If yes, please explain: _____________________________________________

27. Do you have joint problems or any form of arthritis? Yes No

If yes, please describe: _____________________________________________

28. Do you work with chemicals? Yes No

1660 S Columbian Way S-111-EMP, Seattle WA 98108

(206) 277-3575

Do you have symptoms from the chemicals? Yes No

Comments: ______________________________________________________

29. Please note any other health history you consider significant:

30. Immunization/TB Screening History:

Immunization/Test Date Side Effect/Reaction Other

Tetanus (most recent) _______ _________________ ______

Rabies Series, Initial _______ _________________ ______

Rabies Booster _______ _________________ ______

Rabies Immune Globulin _______ _________________ ______

Hepatitis B Series, Initial _______ _________________ ______

Hepatitis B, 2nd Series _______ _________________ ______

Tuberculin Skin Test _______ _________________ ______

Other _______ _________________ ______

Chest X-ray _______ _________________ ______

Signature of Employee: ____________________________ Date: ___________

Print Name: _____________________________________

Signature of Interviewer: ___________________________ Date: ___________

Print Name: ______________________________________