Occupational Health & Safety Program

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.


Before Completing This Form


a researcher in a lab

Tetanus Vaccination:

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.


Mask Fitting:

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.


Training Requirement:

The CITI Program training must be completed every 4 years. Make sure you have completed it. (https://about.citiprogram.org/en/homepage/)

Name*
Date of Birth*
Gender*

Current Status*
Student Status*
Principal Investigator or Supervisor*

Do you need access to the vivarium?

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.

Do you wish to decline participation in the program?*
Please elaborate on why you are declining to participate in the Occupational Health and Safety Program for animal users.*

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

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.

Date (participation declined)*

Participant Acknowledgements

I have completed required CITI training (https://about.citiprogram.org/en/homepage/).*
There are occupational risks related to work with animals.*

Training Requirement


Do not submit this form unless you have completed the CITI Program training at this link:

https://about.citiprogram.org/en/homepage/


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.


Animal Use

Animal/Tissue Use*
Check the option that best describes your status:

Tetanus Vaccine Verification

Have you been vaccinated for tetanus within the last 9 years?*
Date of Tetanus Vaccine (must be within last 9 Years)*
Date of your most recent tetanus vaccination (check with your health care provider if you are unsure of the date)

Vaccination Requirement


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.


Please upload an electronic copy of your tetanus documentation. There is an option below to save your progress and return to this form once you have a digital copy of your tetanus records.*
No File Chosen
File uploads may not work on some mobile devices.
Have you attached an electronic document in the previous step as evidence of your Tetanus vaccine?*

Vaccination Documentation Requirement


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.


Medical History

Potential Animal/Tissue/Body Fluid Exposure*
Have you ever had any problems (such as allergy symptoms, asthma, shortness of breath, coughing, or wheezing) as a result of exposure with animals or substances and chemicals used to work with animals?*
Animal Frequency - 01*
Animal Severity - 01*
Animal Frequency - 02
Animal Severity - 02
Animal Frequency - 03
Animal Severity - 03
Are you allergic to latex, or have you ever had any skin problems from exposure to animal feed, animal bedding, or substances/chemicals used for work with animals?*
Material Frequency - 01*
Material Severity - 01*
Material Frequency - 02
Material Severity - 02
Material Frequency - 03
Material Severity - 03
If you have had a contact reaction due to exposure to animal feed, animal bedding, or substances/chemicals used to work with animals, did you develop respiratory symptoms as a result?*
When was your most recent Mask Fit test?*

Mask Fitting Requirement


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.

Do you have any chronic health conditions that may impact your ability to work with animals? *
For females: Are you pregnant or planning to become pregnant within the next year?*
Have you ever contracted a serious illness from an animal or in animal related work or had an animal inflict a serious injury?*
Will you be working with or have exposure to biohazards, chemical hazards, or radiation/radioactive material during the course of your work?
If you will be working with high risk materials, have you received safety training and are mechanisms in place to protect you?

Additional Information and Documentation

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.

Additional Supporting Documentation
No File Chosen
File uploads may not work on some mobile devices.
Please try to combine multiple documents into one PDF or image file.

Signature of Employee

Date confirming medical history and vaccinations

Authorization to Disclose Protected Health Information

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.

Date (authorization of release)
Save and Resume Later
Progress
Cancel
Confirm