Date: 1. Do you have any ongoing medical problems? Yes; No If yes, explain: 2. Has a physician told you that you have an immune compromising medical condition or are you taking medication(s) that impair your immune system (steroids, immunosuppressive drugs, or chemotherapy)? Yes; No If yes, explain: 3. Have you had a tetanus vaccine/booster in the past 10 years? Yes; No If yes, what year? 4. Does your work involve travel to a foreign country? Yes; No If so, what vaccines (if any) have you already received? 5. Other vaccines that may be relevant to your work (vaccine and year): 6. Have you had any of the following? (Check all that apply) Pneumonia Seizures Liver disease Heart disease Recurrent bronchitis Carpal tunnel or repetitive Diabetes Rheumatic fever motion injury Cancer Arthritis For any box you checked above, additional description can be provided here: 7.Do you have allergies to any of the following: Mice Dogs Weeds Food Rats Frogs Grass Latex Rabbits Reptiles Trees Insect stings Cats Birds Molds Other allergies. Please describe: 8. Please describe any health conditions you think may be pertinent to working with animals:
Date: 1. Do you have any ongoing medical problems? Yes; No If yes, explain: 2. Has a physician told you that you have an immune compromising medical condition or are you taking medication(s) that impair your immune system (steroids, immunosuppressive drugs, or chemotherapy)? Yes; No If yes, explain: 3. Have you had a tetanus vaccine/booster in the past 10 years? Yes; No If yes, what year? 4. Does your work involve travel to a foreign country? Yes; No If so, what vaccines (if any) have you already received? 5. Other vaccines that may be relevant to your work (vaccine and year): 6. Have you had any of the following? (Check all that apply) Pneumonia Heart disease Diabetes Cancer Seizures Recurrent bronchitis Rheumatic fever Arthritis Liver disease Carpal tunnel or repetitive motion injury For any box you checked above, additional description can be provided here: 7.Do you have allergies to any of the following: Mice Rats Rabbits Cats Dogs Frogs Reptiles Birds Weeds Grass Trees Molds Food Latex Insect stings Other allergies. Please describe: 8. Please describe any health conditions you think may be pertinent to working with animals:
ESF_IACUC_OHS_Questionnaire_050717.docx