Annual Update: Animal Handler Assessment, Immunization and Allergy History Form

Fields marked * are required.

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

An annual update health assessment is important in protecting your health and safety. Please complete each section and ask any questions you may have. Thank you!

Part B: Personal Health History Update

I. Immunizations Update

Tetanus Booster*

NoYes

Required in last 10 years. If longer than 10 years, please schedule an appointment with your personal healthcare provider.

If Yes: Year*

Rabies — series of 3 shots required for certain jobs*

NoYes

If Yes: Year*

TB Skin Test — required for certain jobs*

NoYes

If Yes: Year*

II. History

Have your allergy or asthma symptoms worsened since beginning work with animals?*

YesNoN/A

Please explain*

Have you developed any allergic symptoms to any animals?*

YesNo

Please explain*

Have you ever required medical treatment or missed work due to allergy or respiratory symptoms?*

YesNo

Please explain*

Do you have other new allergies?*

YesNo

Please explain*

If yes to any of above, mark allergy symptoms. Otherwise select “N/A”.

N/ACoughWheezeItchy eyesNasal congestionSneezingRashChest tightnessOther

Explain symptoms and include how often — daily, weekly, monthly

Has there been a change in your health or any new medical diagnosis?*

YesNo

Please explain*

Are you under the care of a healthcare provider?*

YesNo

Please explain*

Are you taking any new medications?*

YesNo

Please explain*

I understand the above questions and answered to the best of my knowledge. I do not have any other questions at this time and will contact my healthcare provider if I do. I will also inform the nurse reviewer. I understand that this information is confidential; however, my employer may be informed of any capability to work with lab animals without any disclosure of clinical diagnosis.

Signature or type in name indicating signature*

Typing in your name indicates your signature.

Date*