Fillable Initial Enrollment Forms UTT OCCUPATIONAL HEALTH PROGRAM (University of Texas at Tyler)

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Initial Enrollment Forms UTT OCCUPATIONAL HEALTH PROGRAM (University of Texas at Tyler)

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Initial Enrollment Forms
Return Forms Via Campus Mail to EHS USC 135 or safety@uttyler.edu
UTT OCCUPATIONAL HEALTH PROGRAM
_________________________ _________________________ _______________
Last Name First Name Middle Name Date of Birth
Gender
Male Female Department________________________________ Supervisor/BA __________________________
Job Title______________________ Work phone______________ Cell Phone ______________ E-Mail _________________________
Campus Bldg/Office Location ______________________ Room # ___________ My UTT EID #: _______________________________
Vaccination History (Provide dates as accurately as possible)
Hepatitis A ________________________ Hepatitis B _____________________ Influenza ________________________
Rabies (Rabavert) __________________ Tetanus ________________________ PPD (TB Skin Test) ________________
Chickenpox (Varicella) _______________ MMR __________________________
Tetanus, Diptheria, Pertussis (DPT/Tdap) _________________
Do you work with formaldehyde? ……………………………………………………
No Yes ___________________________________
Do you work with human or non-human primate blood, tissue or cells? ………..
No Yes ___________________________________
Do you work with any infectious agents (i.e., bacterial, viral,fungal, parasitic)?...
No Yes ___________________________________
Do you work with biological toxins (i.e., botulism, conotoxin, tetrodotoxin)? .......
No Yes ___________________________________
Do you work with anesthetic gases (i.e., isoflurane)? ……………………………..
No Yes ___________________________________
Do you work with anti-neoplastic drugs? …………………………………………...
No Yes ___________________________________
Do you work with carcinogens (i.e., benzene, chloroform, dicholormethane)…...
No Yes ___________________________________
Do you work with highly toxic chemicals? …………………………………………..
No Yes ___________________________________
Do you work with heavy metals (i.e., copper, chromium, lead, lithium)? ………
No Yes ___________________________________
Do you work with reproductive hazards (mutagens/teratogens)? ………………
No Yes ___________________________________
Are you exposed to animal waste (carcasses, feces, urine, tissues)? …………
No Yes ___________________________________
Are you exposed to needles/scalpels/sharps? ……………………………………
No Yes ___________________________________
Do you wear a respirator in your work? ..........................................................
No Yes ___________________________________
Do you cut metal by torch or weld > 20 days/year? ……………………………….
No Yes
Are you allergic to latex? ……………………………………………………………..
No Yes
List Animals, Insects or Plants
Do you have close, recurring contact with animals during your work? ………… No Yes ___________________________________
Do you have contact with insects during your work? ……………………………
No Yes ___________________________________
Do you have close, recurring contact with potentially harmful plants or fungi?
No Yes ___________________________________
Acknowledgement and W
aiver Statement – Please read and check items as appropriate prior to signing and dating the form below:
I have reviewed the information concerning the UTT Occupational Health Program in this document and as posted on the website
http://uttyler.edu/safety. I understand that my recurring animal contact or exposure to biological, chemical or physical hazards may have a health risk
exposure, and I am advised to have a health assessment. I also understand health risks are associated with not accepting the health assessment.
I understand that tests or immunizations for my job function / area may be mandatory for full participation in the OHP and that proof of test or immunizations
are needed to meet program requirements.
In full recognition of the above statements please mark one of the following 3 participation choices:
I accept participation in the UTT OHP Health Assessment and will complete the UTSA OHP Health Assessment.
I decline participation in the UTT OHP Health Assessment, but I will contact my personal physician to meet UTT's recommendation for medical
surveillance and I will provide my personal physician with the UTT OHP Health Assessment for my full program participation.
I decline participation in the UTT OHP Health Assessment.
I have read, understood, and answered all parts of this form truthfully, and to the best of my ability and knowledge.
_____________________________________________ ________________________________________
Signature Date
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The University of Texas at Tyler
HEPATITIS B VACCINATION CONSENT OR DECLINATION FORM
Full Name:
UTT EID: Date of Birth:
I understand that due to my potential occupational exposure to blood or other potentially infectious materials
(OPIM), I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be
vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this
time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious
disease. If, in the future, I continue to have occupational exposure to blood or OPIM and I want to be vaccinated
with hepatitis B vaccine, I can receive the vaccination series at no charge to myself.
I understand that due to my potential occupational exposure to blood or OPIM, I may be at risk of acquiring HBV
infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself.
However, I decline hepatitis B vaccination at this time because I have previously received the entire
series of vaccinations. I understand that by declining this vaccine, I release The University of Texas at Tyler
from any liability related to the inadequacy of my previous vaccination. If, in the future, I continue to have
occupational exposure to blood or OPIM and I want to be vaccinated with hepatitis B vaccine, I can receive the
vaccination series at no charge to myself.
I consent to be immunized for the Hepatitis B vaccination (HBV) series. A new consent form
will be completed for each injection in the series.
I have been offered the opportunity for Hepatitis B surface antibody testing.
I accept / decline to have my blood tested at no cost to me 1-2 months following completion
of the HBV vaccine series to determine immunity. A positive result indicates immunity and a negative
result indicates no immunity. If negative, a second 3 dose series will be offered to me and I may be retested.
If I remain negative after a second 3 dose series, I will be referred for a medical evaluation.
I understand and/or have been informed about the following:
1.
I received or was offered the HBV Vaccination Information Sheet (VIS) which lists the indications, benefits, presently
known side effects and adverse reactions of receiving the HBV vaccine.
2.
I have been given the opportunity to ask questions regarding the virus, the vaccine, and my potential
occupational exposure.
3.
I understand there is the potential for localized non-serious side effects such as swelling, redness or soreness which is
generally self-limiting and requires no treatment.
4.
I understand there is no guarantee that I will not experience an adverse reaction or side effect from the HBV
vaccine or antibody testing procedure.
5.
I have never had a serious allergic reaction or other problem to baker’s yeast or after receiving doses of HBV in the
past.
6.
I am not currently pregnant. (HBV may be administered during pregnancy with physician authorization.)
7.
I am not currently ill.
Signature _____________________________________________ Date __________________
Animal Allergy Questionnaire
UTT OCCUPATIONAL HEALTH PROGRAM
Return Forms Via Campus Mail to EHS USC 135 or safety@uttyler.edu
Animal Allergy Questionnaire:
________________________ ________________________ ___________________ _________________
Last Name First Name Middle Name Date of Birth
___________________________ __________________________ __________________________________________
Department
Supervisor/BA Job Title
_________________________ ________________________ ______________________________________
Work Phone Cell Phone E-mail
Animal Contact Yes No if No, skip to next section - Allergy History
Indicate the types of animal contact you will have:
Direct contact and handling of animals
Direct contact and handling of non-fixed or non-sterilized animal tissues, animal fluids, or animal wastes
Direct contact with non-sanitized animal caging or enclosures
Services, repair, or maintenance related support of animal equipment, devices, and/or facilities
Do you have contact with animals outside of work? Yes No
If yes, please list the species______________________________________________________________________
Do you have any of the following symptoms that you feel may cause or make worse, or are the result of working at an
animal facility or with lab animals? Yes No
Watery, burning, or itchy eyes Runny nose Sneezing Shortness of breath
Cough Chest tightness Wheezing Hives Rash
Have you ever changed jobs/work habits because of symptoms from handling animals? Yes No
Allergy History
Indicate any allergic conditions you may have to the following:
Dog Cat Farm Animals Bird (feathers) Sheep (wool) Nonhuman Primates
Rabbit Swine Rats or mice Guinea Pigs Mold Weeds
Latex Grasses Trees Wood Chemicals____________________
Other__________________ Medications
Indicate any medical conditions you may have:
Skin rash Hay fever Chronic coughing Eczema Latex allergy Asthma
Allergic conjunctivitis (itchy, watery eyes from allergies)
Chronic allergies (food, pollens, dust, or chemicals)
Allergic rhinitis (runny nose due to allergies)
A natural parent or sibling with allergies to animals or their substances
Animal Allergy Questionnaire
UTT OCCUPATIONAL HEALTH PROGRAM
Return Forms Via Campus Mail to EHS USC 135 or safety@uttyler.edu
Medical History (check if yes) Yourself Immediate Family
(optional)
Respiratory allergies including hay fever
Asthma
Skin Allergies
Food Allergies
Chronic sinus disease
Smoker or tobacco user
Comments – please list any concerns or other health-related information the Occupational Health physician should know:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I have answered this form truthfully and to the best of my recollection.
_____________________________________________ ________________________________________
Signature Date
Physical Examination
To be completed by OHP Physician/staff
Required; OHP staff will arrange for a physical examination
Not required
Physician Comments
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________ ________________________________________
Physician Signature Date
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Initial Enrollment Forms UTT OCCUPATIONAL HEALTH PROGRAM (University of Texas at Tyler)

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Completed 30 August 2020

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