OHSP APPENDIX VII

 

George Mason University

 

CONFIDENTIAL MEDICAL INFORMATION

 

SIGNIFICANT BIOLOGICAL AGENT OR ANIMAL CONTACT

HEALTH SURVEILLANCE QUESTIONNAIRE

 

Return to:    (Enter name, address, phone of health services group)

 

 

Date:   _____________                                            Chart #:        __________________

 

Name: _____________________________                             DOB:  ___________________

 

University:______________                       

 

 

Medical Record Identifier:     ___________________

 

 

Previous Evaluation at this clinic?   Yes  No            If yes, provide month/year:  ____ / _____

 

Status:           Animal Handler              Research Technician        Veterinarian

                   Investigator                            Other:  ___________________________

 

 

What species of animals or types of biological agents will you be handling?

 

                                                                                                                    

                                                                                                                    

                                                                                                                    

 

 

Medical History

 

Do you have any ongoing medical problems?  If yes, explain.

 

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Have you had (check all that apply)?:

 

 Pneumonia                   Recurrent Bronchitis        Tuberculosis                        

 Heart Disease                Rheumatic Fever            Heart murmur & Valve Disease  

 Diabetes                      Kidney Disease              Liver Disease

 Cancer                        Gastrointestinal Disorder  Loss of Consciousness

 Seizures                       Arthritis                      Chronic Back or Joint Pain

 

Have you been told by a physician that you have an immune compromising medical condition or are you taking medications that impair your immune system (steroids, immunosuppressive drugs, or chemotherapy)?________      

If yes, explain­­­

 

                                                                                                                    

                                                                                                                    

                                                                                                                    

 

 

Are you currently taking any medications? ________ If yes, list

 

                                                                                                                    

                                                                                                                    

                                                                                                                    

 

For Women: Are you pregnant, or planning to be pregnant in the next year?          Yes,  No

 

Allergy History

 

List any allergies to medications:

 

                                                                                                                    

                                                                                                                    

                                                                                                                    

 

Do you have any of the following symptoms (Check all that apply)?:

 

Chronic cough   Asthma          Itchy, irritated eyes

Hay fever        Skin rash         Chronic allergies (food, pollens, dust)

 

Are you allergic to?

 

Dog               Cat                Cattle            Horse         Bird (feathers)

Hog               Primates         Rabbit           Goat           Sheep (wool)

Rat or mice       Guinea Pig       Alfalfa           Weeds         Trees

Grasses           Chemicals        Latex            Wood         Other ____________

 

Immunizations

 

Indicate date of most recent vaccination (or blood test to document immunity).  Mark “X” if you do not recall the date. Mark "?" or leave blank if you are unsure.

 

Measles

 

Mumps

 

Rubella

 

Hepatitis A

 

Hepatitis B

 

Rabies

 

CMV

 

Toxoplasmosis

 

“Q” Fever

 

BCG

 

Vaccinia (“smallpox)

 

Yellow Fever

 

 

 

 

Date of last tetanus booster: _______________

 

Date of last rabies booster: _______________

 

Date of last rabies titer: _______________

 

Date of last serum sample: _______________

 

Tuberculosis Skin Testing

 

Date of last PPD skin test: _______________ Positive,  Negative   

If POSITIVE, date of last Chest X-ray: _______________

If POSITIVE in the past, are you having any of the following symptoms ( check box)?

 

 Fever   Chronic cough  Bloody sputum  Weight loss  Shortness of breath

 

Have you ever contracted a disease from animals, or experienced an animal related injury (including bites, scratches, needlesticks, etc.)?  If yes, please explain below:

 

 

Do you work with species of, or biological material from, non-human primates?     Yes  No

 

Are you involved with recombinant DNA technology?         Yes   No. 

 

If yes, does the research involve techniques in which viable, recombinant DNA-containing micro-organisms are used to infect animals that then require Biosafety level 3 containment?  Yes   No.