Medical History Questionnaire
Information in this questionnaire is intended for investigators, technicians, students, laboratory animal staff, IACUC members, maintenance staff, and anyone who may potentially be exposed to laboratory animals. This information will be confidentially maintained by UNTHSC Clinical Practice Group. A completed questionnaire is required to work with laboratory animals, animal tissue (including cell lines and tumors), and to have key access to the vivarium or other animal use areas on campus.
There will be fields at the end of this form for you to provide additional details in your own words and attach an additional document if needed.
You will not be able to complete this form without attaching documentation of your most recent tetanus vaccination. Documentation must be provided by uploading a digital version (.PDF, .JPG, .BMP, etc.) when you submit this form. If you have not received a tetanus vaccine within the last 9 years call Priority Care at 817-735-5051 to schedule your vaccination.
On this form you will report any animal related allergies or breathing problems. If you have any animal related allergies or breathing problems you need to schedule a mask fit test with Priority Care, 817-735-5051.
The CITI Program training must be completed every 4 years. Make sure you have completed it. (https://about.citiprogram.org/en/homepage/)
If you have decided not to complete this questionnaire and not to participate in this aspect of the program, please date and sign this block. This will have no effect on your employment. However, it may have an effect on your access to the Vivarium and Lab Animals. At any time that you decide to participate in the Occupational Health and Safety Program you must complete this form in its entirety and resubmit.
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You have elected "Yes", declining participation in the Animal Use program.
This election means you will NOT be cleared to work with lab animals, animal tissue, or in the vivarium labs.
Proceed with submitting this form only if you will not work with animals or in the vivarium lab.
Do not submit this form unless you have completed the CITI Program training at this link:
You can save your progress and return after completing the training. When you click the "Save and resume later" link that appears above the Submit button, you will receive an email with a link back to this form.
Anyone working with lab animals, animal tissue, or in the vivarium must have received a tetanus vaccination within the last 9 years. Contact UNT HSC Priority Care at 817-735-5051 to arrange an appointment for vaccination.
You can save your progress with the option below and return to complete this form after vaccination.
You must upload an electronic document as evidence that you received the tetanus vaccine within the last 9 years. The document may be a .PDF, .JPG, .BMP, .TIFF, or .PNG format.
If you submit this form without attaching proof of vaccination, your submission will not be saved unless you select the “Save and Resume Later” button at the bottom of this page. If you select this option, you will be emailed a link to return to this form after vaccination.
You have indicated that you may have allergies or experience health problems when working with animals or lab materials. Please contact Priority Care at 817-735-5051, to schedule a Mask Fit Test at your earliest convenience.
You will not be cleared to work with animals, animal tissues, or in the vivarium until you have completed the Mask Fit Test.
Please save your progress with the link below. You will be emailed a link you can use to return to this form after you've completed your Mask Fit Test.
Use these fields to provide the Occupational Health nurse with any additional details you feel are relevant to your application. If you have multiple documents you would like to provide, please combine them into one PDF and upload them here.
I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer protected. I understand that the specified information to be released may include, but is not limited to: history, diagnosis, and/or treatment of drug or alcohol abuse, mental illness, or communicable disease, including Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS). Such release of records includes all communications regarding those records, results or reports.
I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. I understand that I may be charged a retrieval/processing fee for copies of my medical records according to Texas Hospital Licensing Law.