HARVARD UNIVERSITY Health Questionnaire for Animal Facilities Access
Occupational and Environme ntal Health Net work (OEHN) is contracted by Harvard Univ ersity to provide occupational health services including evaluation for clearance to work in Harvard’s animal research and laboratory facilities. This Questionnaire, and any future related medical records, will be maintained confidentially and will be disclosed only with your prior written consent unless required by law. This Health Que stionnaire is designed to provide OEHN with the following:
a) Information about occup ational exposure and risks associated with the individual identified in Section 1.1;
b) Medical information related to your ability to safely perform the functions of the position; and c)A baseline medical history for ongoing medical surveillance purposes.
Providing responses to the Medical Health Histor y inquiries in Sections 3.1, 3 .2, 3.3, and 3.4 below is entirely volunt ary as is providin g the Con sent requested in Section 5.0. If you choose to share this information, OEHN will be better able to provide you with appropriate counseling and guidance regarding occup ational exposure and risk.
For Longwood: Please email s igned questionnaire to: TErcolini@oehn.net Cc: tyla_mitrano@hms.harvard.edu
Check
Section 1.0: Identification and Occupational Exposure
Section 1.1: HARVARD ID #:
First Name: Last Name:
Gender: Email:
Work phone #: Cell or home phone #:
Employer: FAS/SEAS HMS HSDM HSPH
PI/Faculty Adviser/Supervisor Name:
Phon e #:
Position Description: (Check all that apply)
Other (please specify):
Email:
Principal Investigator Researcher Environmental Health and Safety
Veterinary / Animal Care Tech IACUC Member or Staff Campus Services / Emergency Response / Public Safety Visitor
Other (please indicate):
Please indicate the Workpla ce type(s) below whose primary use best fits the type of Workplace the position requires wo rk or access to. For example: If the position is administrative but within an animal care facility, the workplace type is Animal Care Fa cilit y.
Research Laboratory Teaching Labo ratory Animal Care Facility
Other (please indicate):
Please identify the biosafety level(s) where access is required below (Check all that apply).
No biosafety level access BSL 3
Section 1.3: Workplace Environment (Check all that Apply)
2
1
Please indicate whether this position requires work, contact, or access to the following research materials or subjects by checking th e applicable bo xes belo w
Human cells, tissue, or blood Class 3b or 4 lasers Radioactive material
HARVARD UNIVERSITY Health Questionnaire for Animal Facilities Access
Section 2.0: Risk Assessment
Section 2.1: Expo sure to Animals (Please identify the type(s) of animal species you will work with below.)
Rodents (mice, rats, hamsters, gerbils) Fish, frogs, or other aquatics
Small animals (rabbits, chinchi llas, guinea pigs) NHP (Macaque, other)
Pigs
Section 2.2: Expo sure to Infectious Agents
Will you work with biological agents? YES NO
Other (please specify):
If ‘YES’, please li st the type(s) below. Please contact your PI or lab manager if you have questions.
Bacterial (please specify):
Virus (please specify ):
Fungi (please specify):
Parasites (please specify):
Section 3.0: Medical Health History (voluntary)
Section 3.1: Aller gy and Respiratory System Health History (voluntary)
I decline to provide this information and understand that I do so at my own risk.
YES NO
Asthma or other chron ic respiratory disease
Allergic skin reactions such as hives, rash or itching. If yes, please explain:
Skin condition s su ch as eczema, psoriasis, dermatitis.
Known or suspe cted animal allergies. Please check off any animal-related reaction(s): Runny/stuffy nose Sneezing Coughing Wheezing Chest tightness
Shortness of breath Hives Skin rash Throat swelling
If yes, please list animal(s):
Known or suspe cted allergies to chemicals, latex, food, or environment. If yes, please list:
Are you currently using respiratory protection or a mask?
If yes, have you been fit-tested? Please list type of respirato r/mask you are using:
Section 3.2 Immune/Metabolic System Health History (voluntary)
I decline to provide this information and understand that I do so at my own risk.
YES NO
Chronic health conditions such as diabetes.
Valvular heart disease.
Would you like to speak with an occupational health provider for reproductive health counseling (in case you or someone in your household is pregnant or planning to become pregnant)? If yes, an OEHN clinician will contact you.
Kidney or liver disea se
History of spleen problems or absence of spleen.
Immune system deficiencies or other limitation s to your ability to fight off disease or infec tion (i.e., cancer, lupus, organ transplant, HIV infection, chronic infections, take oral steroids, TNF inhibitors). If yes, please list:
Do you have any question s concerning your health a s it rela tes to the workpla ce that you would lik e to discuss with an occupational health professio nal? If yes, an OEHN clinician will contact you.
HARVARD UNIVERSITY Health Questionnaire for Animal Facilities Access
Section 3.3: Immunizations (voluntary)
I decline to provide this information and understand that I do so at my own risk.
Please check the boxes to indicate which immunization s you have received in the past: Tetanus/diphtheria or Tdap Varicella (Chicken pox)
Other: Measles Hepatitis B
Section 3.4: Tuberculosis Scre ening (voluntary)
I decline to provide this information and understand that I do so at my own risk.
Date of your last TB t est? If history of positive TB test, please indicate date:
Section 4.0: Release of Information
If OEHN recommends that diagnostic tests or treat ment be performed by other providers, your prior consent will be re quired before your medical records are relea sed by OEHN. You may request a copy of your medical records maintained by OEHN by submitting a written request to OEHN (5 Mount Royal Ave., Suite 50, Marlborough, MA 01752, Attn: Medical Records).
Section 5.0: Consent for Examination (voluntary)
I decline to provide my consent and understand that I do so at my own risk.
I hereby grant permission for OEHN to engage in routine examinations or diagnostic tests necessary to assess my ability to perform my job, to contact me about the results of any such evaluation , and to offer immunizations or other treatment with the goal of attaining or maintaining my clearan ce to perform my job.
Section 6.0: Consent for Evaluation
I hereby aut horize OEHN to review my responses to this Health Questio nnaire and to notify me of any other evaluation or treatment necessary for diagnosis or cle arance.
I have completed this questio nnaire truthfully, and underst and that completing Sections 3.1, 3.2, 3.3, 3.4, and 5.0 is vol untary, and that OEHN’ s evaluation of information contained in this questio nnaire was requested by Harvard University in connect ion with its occupat ional health services program. I kno wingly and voluntarily authorize OEHN to use such health information as I ha ve pro vided in its determination of my clearance status. I understand that I remain subject to Harvard’s policies without regard to whether I provide responses. If I decline to provide responses, I further understand that OEHN will not be able to provid e Harvard with an assessment o f my health and fitness for occupationa l exposure to the risk s associated with my job and that there may be safety -sensitive circumstances under which I may be denied use of and/or access to Harvard’s animal research and l aboratory facilities I hereby further authorize Harvard and OEHN to transfer any record s maintained hereunder for purposes of occupational health treatment, payment, or op erations.
Individual Signature:
Signature of Parent/Guardian (if individual is under 18):
Print Name of Parent/Guardia n (if individual is under 18):
