Annual Medical Surveillance Questionnaire
Completion of this form is an annual requirement for all CU Denver/Anschutz employees who work with animals or hazardous materials. Access to the CU Anschutz
vivarium may be denied if this form is not completed on an annual basis. All information is privileged and confidential. There is no charge for processing this form.
SUBMISSION INSTRUCTIONS: This form can be emailed, mailed or submitted in person. THE PREFERRED METHOD IS ELECTRONIC. ADDRESS: Occupational Health
Program, Mail Stop H275, 12348 East Montview Blvd., 2nd Floor, Aurora, Colorado 80045
EMAIL: Occupational.Health@ucdenver.edu PHONE: 303-724-9145 FAX: 303-724-9213
Section 1.0 Personal Information
Name:
Gender:
Date of Birth: Today’s Date: Speed Type:
ID:
Job Title:
Campus: AMC Downtown VA DH Boulder CSU Other: Dept.:
Work #:
Cell #:
Building and Lab Room #:
Protocol #:
Email:
List all PIs:
I am a PI who does not actively engage in lab/bench work and never goes into the vivarium
If checked, do not complete sections 2-4. Sign and date at bottom and submit to Occupational Health.
Section 2.0 Exposure Information
1. Select the animals that you have contact with at work
NO CONTACT WITH ANIMALS Recombinant DNA (rDNA)
Rodents (mice, rats, hamsters, gerbils, rabbits, chinchillas) Human cells, tissue, or blood
Guinea pigs: Hairless Haired
Radioactive material
Cats
Anesthetic gas use
Pigs: Awake Anesthetized Only Anti-neoplastic drugs
Sheep
Cows
Fish, frogs, or other aquatic animals
Unfixed animal tissue (list):
Field studies
Infectious agents (list):
Others (list):
Teratogens or carcinogens (list):
NO CONTACT WITH HAZARDOUS MATERIALS
Section 3.0 Medical History
1. Do you have any new allergies to animals or latex? Yes
No
If so, please list them:
2. Do you have any of the following symptoms while working with animals:
Watery, burning , or itchy eyes Sneezing or coughing
Chest tightness
Skin rash or hives
Runny nose
Wheezing
Shortness of breath N/A
3. Are you immune-compromised or have any significant medical issues? Yes No
If so, please specify:
Section 4.0 Employee Signature Certification: I verify the information is correct.
Employee Signature: ___________________________________________________ Date:______________
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signature
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