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University Health Services - Employee Health

Interim 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
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

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

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

  1. List illnesses/conditions that you are currently being treated for::
  2. List surgery procedures since your last visit with us:
  3. Are you allergic to any animal(s)? Yes - No
    If yes, list animal(s) that cause your allergy symptoms:
    List symptoms that occur when you are suffering from your allergies:
    List treatment you receive to relieve your allergies:
    Have you been seen by a physician for allergy symptoms or asthma specifically related to animals that you currently work with? Yes - No
    Please explain:
  4. Do you have any other known allergies? Yes - No
    If yes, list cause(s) and symptoms:
  5. Do you have asthma? Yes - No
    If yes, list cause(s) of asthma:
  6. 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:
  7. Do you wear a fitted respirator or mask to prevent allergy symptoms when working with animals? Yes - No
  8. 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
  9. List any medications you take on a regular basis?
  10. Are you pregnant or do you plan to become pregnant in the next year? Yes - No
  11. Have there been any animal-related exposure incidents (i.e. bites, scratches, needle sticks) since your last Employee Health visit for which there was no health care follow-up or for which you might have some medical concern? Yes - No
    If yes, explain:
  12. Since you began working with animals at Princeton University, have you noticed any change in your health? Yes - No
    If yes, explain:
  13. Have you experienced any of the following symptoms which you relate to your exposure to research animals or your time in the vivarium?
    Difficulty breathing Yes No
    Chronic cough Yes No
    Asthma Yes No
    Itchy/irritated eyes Yes No
    Skin rash or hives Yes No
    Runny nose Yes No
  14. Have these symptoms required any treatment by a physician or with over-the-counter medications? Yes - No
  15. 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:


    

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