Fields marked * are required.
Animal Handler Occupational Health and Allergy Assessment Form
This form supports the occupational health surveillance program for personnel working with animals. Its purpose is to identify any health risks, allergies, or conditions that may require protective measures.
Name*
Company*
Email*
Phone Number*
Manager*
Position*
How often do you go to Mispro?*
How long are you there?*
For what reasons?*
Please explain tasks performed when there*
All Information is Strictly Confidential
This CONFIDENTIAL Occupational Health Assessment form must be completed when work with animals begins and each year thereafter. The form is reviewed by a licensed healthcare professional who may request additional information.
Section A – Animal Exposure and Work Activities
1. Have you worked with research animals in the past?*
NoYes
Length of time — years*
List which animals*
2. Please describe the current work performed requiring Animal/Tissue Use. Check all that apply.*
No direct contact – observe animals or enter facility onlyHandle unfixed animal tissues or body fluids (no live animals)Handle, restrain, or administer substances to live animalsPerform invasive procedures (e.g., surgery, necropsy)
3. Current exposure to animals/tissues/fluids. Check all that apply.*
AmphibiansRodents (bred)Rodents (wild)BatsBirdsCattleChickensRabbitsCatsDogsMonkeysPigsSheepGoatsHorsesReptilesFishFerretsOther
If Other, please explain
4. Other potential exposures — chemicals, infectious agents, or bloodborne pathogens. Explain:
Section B – Immunization History
Please indicate your most recent immunizations:
Tetanus*
If Yes: Year*
Booster recommended every 10 years.
Rabies — required for certain jobs*
TB Skin Test — required for certain jobs*
Section C – Allergy and Health History
1. Are you allergic to any animals?*
YesNo
If yes, list*
2. Do you have other known allergies?*
If yes, describe*
3. Do you notice allergy or respiratory symptoms while at work, but not at home?*
If yes, please explain*
4. Do you consistently use required PPE when working with animals or bedding?*
Please check all that apply*
RespiratorGlovesGownGogglesOther
5. Symptom History
Check severity for each symptom due to animal allergies.
Cough*
NoneMildModerateSevere
Wheeze*
Itchy eyes*
Red eyes*
Congestion*
Sneezing*
Rash*
Chest tightness*
Shortness of breath*
Other symptom
Other symptom severity
6. Have you been diagnosed with asthma?*
Explain including year diagnosed and medication*
7. Do you have any chronic conditions, e.g. high blood pressure, diabetes, seizures?*
Explain*
8. Do you take any medications?*
If yes, please list*
9. Do you have or are you immune deficient/suppressed?*
Voluntary explanation
10. Are you pregnant?*
YesNoN/A
Or trying to become pregnant?*
11. Do you have any back or other musculoskeletal issues?*
Please explain*
12. Do you have any other concerns or health issues?
Section D – Certification and Signature
I understand the above questions and answered each to the best of my knowledge. I understand that this information is confidential and will be reviewed by a licensed healthcare professional. I will notify the Occupational Health Nurse if I develop symptoms or changes in health related to animal exposure.
Signature*
Or type full name which is confirmed as signature.
Date*
If you experience symptoms or changes in your health status, contact the Occupational Health Nurse at (919) 676-2877.