Louis Stokes Cleveland VA Medical Center Personnel Health Laboratory Animal Allergy Questionnaire Follow-Up

Transcription

1 Louis Stokes Cleveland VA Medical Center Personnel Health Laboratory Animal Allergy Questionnaire Follow-Up * This form should be completed only by employees who have completed an INITIAL questionnaire in the past. The INITIAL questionnaire should be used as a baseline when evaluating responses to the questionnaire. Demographic Information 1. Name: Last First Middle Initial 2. Social Security Number: 3. Current Job Title: 4. Work Status: (Circle one) VA paid employee WOC Student Contractor CWRU student * Since your last questionnaire, have you changed job title? Yes No If yes: Date of change? Where do you work? Location: Building: * If you are currently working at Case Western University Animal Research Lab: Are you currently enrolled or have you started your enrollment with Case Western Reserve Health Services Yes: No: Not Sure: 5. Are you currently pregnant? Yes No N/A Near future plans? 6. Please list all current medications: Current Allergic Symptoms 7. Please list current allergies to: (Environment / Medications): 8. Specific allergies to: Cat Rabbit Guinea Pigs Dog Mice Other Animal: (please list) Bird Rats Occupational History 1

2 9. Total amount of contact hours/time at work with animals per day: List those animals you are exposed to outside of Home/work: Have you developed any disorders or illnesses since your last questionnaire\personnel Health examination? If yes, Please explain Since your last physical examination has a physician diagnosed you with any allergies or pulmonary disease? (i.e. COPD, Asthma, RSV, etc.) Yes No Not Sure If Yes, Please explain 10. Have you ever had Tuberculosis disease (TB)? Yes No Have you been tested for TB in the past year? What were the results? Positive Negative When was the test performed? Some people have been immunized against TB with a vaccine called BCG. This may make your skin test positive forever. Have you received BCG? Yes No Don t know Are you receiving immunosuppressive therapy such as prednisone, steroids or anti-cancer drugs? Yes No if yes, please list with amount: 11. Have you received a Tetanus booster in the past 10 years? Yes No When did you receive the Tetanus booster? (Date :) Have you ever received Hepatitis A vaccine? Yes No Don t know Have you ever received Hepatitis B vaccine? Yes No Don t know Have you ever had Hepatitis B? Yes No Don t know Have you ever been diagnosed with Hepatitis C? Yes No Don t know COMPLETE THIS SECTION ONLY IF YOU WORK WITH ANIMALS AT THE LOUIS STOKES CLEVELAND VAMC THAT MAY HARBOR RABIES. (This section only pertains to those individuals that the CDC recommends rabies vaccines for). If No / Not Applicable, Please check the Skip section below. SKIP: 12. Have you received a Rabies vaccination (if applicable)? Yes No If yes please list date: When was your last Rabies titer? Date: Results of your Rabies titer: Immune: Not Immune: 2

3 13. Since you started working handling animals, have you experienced any of the following? a. A change in your health status that may make you more susceptible to infection? Yes No b. A change in your pulmonary health status which may affect your use of a face mask? Yes No Personal Protective Equipment/Clothing and Hygiene Practices: 14. Do you ever smoke, eat, drink, apply cosmetics or handle contact lenses in animal handling rooms? Yes No If yes, please explain: 15. When working with animals, do you always wear? Gloves Yes No Mask Yes No Protective Eyewear Yes No Gown/lab coat Yes No 16. Do you perform the following after handling animals at work? Wash hands Yes No Shower/change clothing Yes No Have you been issued a respirator? Yes No Do you wear a respirator? Yes No Hypersensitivity: 17. Do you have a history of hay fever, asthma, or allergic skin problems? Yes No 18. Do you have a family history of hay fever, asthma, or allergic skin problems? Yes No 19. Do you have sneezing, runny nose, watery or itchy eyes, coughing, wheezing, or SOB after working with the Animals or their cages? Yes No If Yes, which species? If Yes, which symptoms? 20. Do you have any house pets? Yes No If yes, which type? Risk of injury-which animals will you have contact with (check all that apply)? Low Risk Mild Risk Moderate Fish or amphibians Rats, Mice, Rabbits, guinea pigs, hamsters, gerbils, birds, and swine with mild risk of injury (primary bites, and scratches, zoonotic disease, but significant potential for allergies.) Dogs, cats, sheep, cattle, goats and wild rodents with moderate risk of injury (primarily 3

4 Risk Marked Risk bites, scratches, kicks, and crushing), zoonotic disease (rabies, Q fever, Hanta Virus, bacterial and fungal infections), and significant potential for allergies. Non-human primates with marked risk of injury (primarily bites and scratches). Zoonotic disease (herpes B virus, tuberculosis, viral hepatitis, bacterial infections), bacterial or viral infections (class 2 or greater) used in research, and some potential for allergies. I certify that this information provided above is true to the best of my knowledge. I understand this review is a generalized review aimed for ensuring a safe working environment. I also understand I must immediately go to Personnel Health or Urgent Care if I have a reaction/bite/scratch to any animal or agent within the Louis Stokes Cleveland VA Research Animal Handling area. I understand that I am expected to adhere to Federal research/occupational health & safety regulations (VHA Handbook ; CFR Title 10, Part 20 and Title 29, Part 1910; MCP-PSCL-002) and failure to do so will result in administrative action. I understand that I must re-submit the Annual Questionnaire upon changes to my health status. I have received training by Research Services that included the use of personal protective equipment and counseling as to the potential risk for zoonotic diseases. Print Name: Signature: Date: Personnel Health Provider or Medical Representative Signature: Date: 4

5 LICENSED HEALTH CARE PRACTITIONER OPINION The above recommendation from the Agency Medical Officer applies to the following program: Animal Allergy Driver Exam Other - specify: MEDICAL CLEARANCE WILL EXPIRE ONE YEAR FROM THE DATE OF THE AGENCY MEDICAL OFFICER S RECOMMENDATION UNLESS OTHERWISED NOTED. RENEWAL OF MEDICAL CLEARANCE CAN BE COMPLETED WITHOUT IN-OFFICE VISIT THROUGH COMPLETION OF ANNUAL QUESTIONNAIRE, PLEASE SEND TO PERSONNEL HEALTH 170(W) APPLICANT IS DUE FOR NEXT IN-OFFICE MEDICAL EVALUATION ON: 5

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8 NOTE TO EXAMINING PHYSICIAN: The person you are about to examine will have to cope with the functional requirements and environmental factors circled side of this form. Please take them, and the brief description of job duties above them, into consideration. 1. HEIGHT: FEET, INCHES WEIGHT: POUNDS BMI 2. EYES: (A) Distant vision (Snellen) without glasses: right left without glasses: right ;with glasses, if worn: (B) What is the longest and shortest distance at which the following specimen of Jaeger No. 2 type can be read by the applicant? Test each eye separately. Jaeger No. 2 Type Employees in the Federal classified service as may be requested by the Civil Service Commission or its authorized representative. This order will supplement the Executive Orders of May 29 and June 18, 1923 (Executive Order, September 4, 1924). left right with glasses, if used: in to in right in to in in to in left in to in 20 left 20 ( C ) Color vision: Is color vision normal when Ishihara or other color plate test is used? YES If not, can applicant pass lantern, yarn, or other test? YES NO NO 3. EARS: (Consider denominators indicated here as normal. Record as numerators the greatest distance heard.) Ordinary conversation:whisper Audiometer (if given) : RIGHT EAR LEFT EAR 20 FT 20 FT OTHER FINDINGS: In items a through l briefly describe any abnormality (including diseases, scars, and disfigurations). Include briefly history, if pertinent. If normal, so indicate. a. Eyes, ears, nose, and throat (including tooth and oral hygiene) e. Abdomen b. Head and back (including face, hair, and scalp) f. Peripheral blood vessels c. Speech (note any malfunction) g. Extremities d. Skin and lymph nodes (including thyroid gland) h. Urinalysis (if indicated) Sp. gr. Sugar Blood I. Respiratory tract (X-ray if indicated) Albumin Casts Pus j. Heart (size, rate, rhythm, function) BP: Pulse: T EKG (if indicated): k. Back (special consideration for positions involving heavy lifting and other strenuous duties) l. Neurological and mental health CONCLUSIONS: Summarize below any medical findings which, in your opinion, would limit this person's performance of the job duties and/or would make him a hazard to himself or others. If none, so indicate. No limiting conditions for this job Limiting conditions as follows: 8