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Animal Exposure Questionnaire

This questionnaire is designed to identify individuals with substantial contact with animals for the purpose of risk assessment and disease prevention. All investigative personnel with substantial animal contact must complete the form. New hires and individuals added to existing animal protocols ail complete this form at the time of initial exam. If you have an questions, please contact us at ARC Occupational Health Contact

Personal information:

Today's Date:

Last Name:        
First Name:             MI:   
CWRU ID Number:
Job Title:   
E-mail:        
Mail Stop:
Phone:         
Dept:      
College:
PI Name:    
PI E-mail:

Status - Check all that apply (NOTE: This applies to full-time and part-time employment):

Faculty Staff Undergraduate Student Grad Student Post-Doc Volunteer
Technical Service Other - please describe:

ALL QUESTIONS MUST BE ANSWERED. IF A QUESTION DOES NOT PERTAIN TO YOU, PLEASE MARK N/A.

1. Have had routine exams/check ups related to your work with animals?

Yes No

2. Where did you receive the exam?

University Hospital CWRU Metro Health Medical Center N/A

3. Date of most recent exam: Month: Year

4. Describe your average weekly exposure to animals:

>8 hours per week
1 - 8 hours per week
<1 hour per week
None

5. What animal related activities are your involved in?

Hands-on work with animals and/or bedding
Work with unfixed animal tissues and fluids
No direct contact, but enter animal areas
None

6. List the species with which you have direct contact (Simply entering the facilities is not considered direct contact): (Check all that apply)

Mice Rat Guinea Pig Gerbil Rabbit Dog Cat Ferret Pig Goat Cattle Sheep Fish Poultry Reptiles Amphibians Wildlife Other (Please Describe) None

7. ARC Facility where work is performed: (Check all that apply)

Wearn Transgenic Mouse Facility

Health Sciences Animal Facility

Metrohealth Medical Center

ARC Rooms:

8. Describe your specific duties related to animal care and support:

9. What is the date of your last tetanus booster? Month Year

10. Have you completed a series of three rabies immunizations? YES NO

If YES, provide the date:Month Year

11. If you are currently working with non-human primates, have you had an annual TB skin test?
Yes No N/A

12. Have you ever had any problems (e.g., shortness of breath, coughing, wheezing or skin problems) while working around animals? YES NO

If YES, please describe:

12. Will any of the following be used in conjunction with the animals that you will be caring for?
Chemicals Biohazards Radioisotopes N/A

Describe the type of hazard exposure if applicable:


13. Other comments or information related to your animal exposure:

Please be advised that certain medical conditions can increase your potential risk of health problems
when working with animals. These medical conditions could include but are not limited to allergies to
animals and/or animal dander, asthma, heart valve disease, immunosuppression and chronic back injury.
You should also be aware that animals kept at home could have an impact on your ability to perform
certain animal care duties with selected species of animals. If you have pets or farm animals at home, be
sure to inform your supervisor.