Health questionnaire for animal handlers working with Laboratory Animals
Please answer the following questions to the best of your ability and click submit when finished.
Identifying Information:
First Name:
*Please enter your first name.
Last Name:
*Please enter your last name.
Telephone:
ext.
*Please enter a valid telephone number.
WVU ID Number:
(if known)
*Please enter your WVU ID Number.
Email Address:
*Email address is invalid.
Reason for animal contact:
Species Involved:
*Please enter a species.
Medical History:
Have you ever been treated for:
1. Allergies, allergic rhinitis, conjunctivitis, or hay fever
Yes
No
*Please select one.
2. Anaphylaxis (Severe Allergic Reaction)
If yes, what caused your anaphylactic reaction?
Yes
No
*Please select one.
*Enter cause of reaction.
3. Asthma
Yes
No
*Please select one.
4. Chronic cough
Yes
No
*Please select one.
5. Eczema, urticaria, or hives
Yes
No
*Please select one.
6. Has treatment for conditions in questions 1-5 (above) ever required hospitalization
Yes
No
*Please select one.
7. Have you received a tetanus booster within the past 5 years
If no, what year did you receive your last tetanus booster?
Yes
No
*Please select one.
*Enter date of last tetanus booster.
8. If you have issues related to working with Laboratory animals are you currently being seen by Occupational Medicine
Yes
No
*Please select one.
9. Do you want to talk to a doctor about how working with animals might affect your health?
Yes
No
*Please select one.
Animal Allergy Specific Questions:
Have you ever had any of the following associated with animal exposure:
10. Itching, tearing, or swelling of the eyes
Yes
No
*Please select one.
11. Nasal discharge
Yes
No
*Please select one.
12. Coughing
Yes
No
*Please select one.
13. Chest Tightness or Wheezing
Yes
No
*Please select one.
14. Skin Rash or itching
Yes
No
*Please select one.
15. Have you ever been advised to avoid contact with animals for medical reasons
Yes
No
*Please select one.
16. Have you received training in the species-specific risk associated with the species you will be working with?
Yes
No
*Please select one.
This questionnaire is administered by the Office of Research Compliance.
For any questions please call 293.7073 or email
ORCTraining@mail.wvu.edu
