University Health Services - Employee Health

Initial Health History Form for those with potential exposure to animals (Confidential)

* Denotes required field

Date*

Name* A value is required.

NetID: (Log-In ID)* A value is required.

University ID#:* A value is required.

Department* A value is required.

Date of Birth*

Phone Number*

Last 4 digits of SS#:*

Supervisor/PI:*

Your Status
Faculty
Staff
Grad Student
Undergrad (Class of)
IACUC Committee
Outside Contractor

A. Animal Use

1. Check the box that best describes your status
(check all that apply)

I enter the vivarium to perform maintenance or service work
I am involved with research of animals or animal tissues in Princeton University lab space.
I am involved with research of animals or animal tissues in the field
List field location(s):
I am involved with veterinary care or animal husbandry.
I am an IACUC member

2. Vivarium: Check the animal facility you will enter
(check all that apply):

Moffett
Princeton Neuroscience Institute
Lewis Thomas Lab
Schultz
Icahn (Genomics)
Eno
Guyot
Other (List Facility)

3. Animal/Tissues/Body Fluids
(check all that apply):

Animal	Daily	1-4x per week	1-3x per month	Infrequent < 11 times/year
Rats
Mice
Wild Rodents
Rabbits
Guinea Pigs
Birds
Reptiles
Fish
Non-Human Primates
Macaque
Marmoset
Other -

4. Describe the potentially hazardous materials that may be used in conjunction with your animal work.

Infectious Agent (including human blood, tissues, cell lines) Yes - No
If yes, please list:
Anti-neoplastic agents (chemotherapy) Yes - No
If yes, please list:
Other hazardous chemicals Yes - No
If yes, please list:

Personal Health History

Have you conducted animal research in the past? Yes - No
If yes, how many years:
List species:
Do you have any other known allergies? Yes - No
If yes, list cause(s) and symptoms:
Do you have asthma? Yes - No
If yes, list cause(s) of asthma:
Do you have any skin problems related to work, such as reactions to latex gloves, rashes, dry and cracked skin?
Yes - No
If yes, explain:
Do you wear a fitted respirator or mask to prevent allergy symptoms when working with animals? Yes - No
Do you have an immune-compromising medical condition or are you taking medication that may impair your immune system? Yes - No
Certain pre-existing medical conditions can place an individual at greater risk of injury or illness in the animal care setting. Disclosure is not required, however you may want to exclude yourself from working in an animal environment if you believe you may be at risk. Consult with your physician if you think you have any of the following or other conditions that may impair your immune system.

Congenital immunodeficiency

Acquired immunodeficiency

Cancer

Pregnancy

Organ or tissue transplant recipient

Allergic condition

Immunosuppressive drug therapy
List any medications you take on a regular basis?
Are you pregnant or do you plan to become pregnant in the next year? Yes - No

Have you had:

Tetanus Immunization	Yes	No
Measles vaccine	Yes	No
Measles titre	Yes	No
Measles illness	Yes	No
Tuberculosis	Yes	No
BCG vaccine	Yes	No
Positive PPD in the past	Yes	No

Do you have any concerns that you would like to discuss with University Health Services clinicians or your own personal physician about workplace issues not covered by the questionnaire that you feel may affect your health? Yes - No
If yes, explain: