Fillable Medical Surveillance Questionnaire Contact Information Department of Environmental (Wright State University)

Fill Online, Printable, Fillable, Blank Medical Surveillance Questionnaire Contact Information Department of Environmental (Wright State University) Form

Use Fill to complete blank online WRIGHT STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Medical Surveillance Questionnaire Contact Information Department of Environmental (Wright State University)

On average this form takes 22 minutes to complete

The Medical Surveillance Questionnaire Contact Information Department of Environmental (Wright State University) form is 2 pages long and contains:

  • 0 signatures
  • 101 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wright State University

BROWSE WRIGHT STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Medical Surveillance
Questionnaire
For Personnel Working
with or around Animals
Department of Environmental
Health and Safety
3640 Colonel Glenn Hwy.
Dayton, OH 45435-0001
(937) 775-2215
Contact Information
Personnel Status:
Faculty Staff Student Visitor
Name (Last, First, MI) Department E-mail
Supervisor's/PI's Name Campus Address Telphone #
Indicate the type(s) 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
Service, repair, or maintenance-related support of animal equipment, devices, and/or facilities
Estimated / known duration of the project, research, or duties involving animals:
Indicate all of the species of animals you will be exposed to - this includes direct contact with animals, animal tissues, and/or
animal wastes, and animal enclosures/cages/bedding:
Dogs
Wild Mammels
Non-human Primates
Cats
Sheep
Rabbits
Rats or Mice
Other
Birds
Guinea Pigs
Farm Animals
Reptiles/Amphibians
Fish Pigs
Do you have contact with animals outside of work?
Yes
No
If yes, please list the species:
Last 4 digits of SS or U number:
Do you have any of the following symptoms that you feel are caused by, made worse, or are the result of your
work in an animal facility or with laboratory animals?
Watery, burning, or itchy eyes
Cough Chest tightness
Runny nose
Wheezing
Sneezing
Hives
Shortness of breath
Rash
I understand that due to my occupation and/or potential exposure to animals I may be at the risk of acquiring zoonotic
diseases and/or animal related allergies .
Yes
No
Wild Non-Mammels
Will you be working with animals as part of a research project?
Will you be working with animals as part of an academic class?
Course number:
NY
NY
Will you be entering the Laboratory Animal Resources Facility but not working directly with animals?
NY
If you answered "NO" to all three of these questions, then STOP and return this form.
Hepatitis A:
Immunizations - year of last documented:
Rabies:Pertussis:
Measels/Mumps/Rubella or MMR:
Hepatitis B:Tetanus/Diptheria:
TB/Tuberculin test:
Wright State Environmental Health and Safety
Medical Surveillance Form 2019-06-08
Chronic coughing
Chronic allergies (food, pollens, dust, or chemicals)
A natural parent or sibling with animal related allergies
Hay fever Skin rash Asthma Allergic conjunctivitis (itchy, watery eye from allergy)
Allergic rhintis
Indicate any medical conditions you may have:
Medical History (Check if yes)
Self Immediate Family Details
Respiratory Allergies, including Hay Fever
Asthma
Skin Allergies
Food Allergies
Chronic Sinus Disease
Lung Disease
Heart Disease
Kidney Disease
Diabetes Mellitus
Cancer
Compromised Immune System
Any type of auto-immune disorder
Hepatitis B / Hepatitis C
Sickle Cell Disease, G6PD Defeciency
Women:
Y N
Pregnant, attempting pregnancy, or breast feeding:
If yes, list medications:
Are you currently on any medications?
Y N
Please list any concerns or other health-related information
the occupational health physician should know:
Date:
Signature
Fill out and hand-deliver to Environmental Health and Safety (EHS)
047 Biological Sciences II
EHS Approval:______________
Chemicals
Weeds
Non-Human Primates
Mold
Sheep (wool)
Wood
Guinea Pigs
Bird (feathers)
Trees
Rats or Mice
Farm Animals
Grasses
Medications
Latex
Rabbit
Dog
Indicate any allergic conditions you may have to the following:
Allergy History
Swine
Cat
Other
For Office Use Only
Investigator name:_______________ AUP #:_______________ LAR Approval:_______________
Print Name
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Medical Surveillance Questionnaire Contact Information Department of Environmental (Wright State University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document