MIT Medical Department

Animal Contact Baseline Occupational Health Questionnaire

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As a result of your potential contact with laboratory animals or their tissues, you are required to participate in the MIT Occupational Health Risk Assessment program. Please complete this Occupational Health Questionnaire which will be reviewed by a clinician in the Employee Health and Occupational Medicine Service (EHOM) at MIT Medical. Based on your answers, you may be requested to schedule an appointment to get further information and/or to obtain appropriate immunizations or other control measures to ensure your good health.

The Occupational Health Risk Assessment program is co-administered by DCM, EHS, and the CAC. However, all personal health information is strictly confidential and is only reviewed and filed at MIT Medical and cannot be released without your written consent.

Questionnaires can be submitted either:

1. Electronically via this page.: https://ehs.mit.edu/medical/survey/survey.php.
2. On paper by printing and completing this form and sending it directly to: MIT Medical Employee Health and Occupational Medicine service (EHOM: E23-135; do NOT send this form to the Committee on Animal Care or the Division of Comparative Medicine)
3. In person by scheduling an appointment with a clinician in the EHOM (Jackie Sherry RN, ANP, 617-253-8552: E23-135)

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Identification information:

Kerberos ID
First Name		Last Name
Department		Building/Room
Work Phone		E-mail
Principal Investigator First Name		Principal Investigator Last Name

Occupational and Medical History:

1. What is your job title?

2. What research animal species will you possibly have contact with?

   • Non-Human primates
   • Rodents
   • Other live animals; list here:
   • None of the above

3. Please indicate which hazardous materials you may be exposed to in your work:

   • Biological materials from humans or non-human primates (blood, tissue, bodily fluids)
   • Biological materials from other animal species (blood, tissue, bodily fluids). List species if known:
   • Infectious agents known or suspected to infect humans. List agents if known:
   • Radioisotopes
   • Carcinogens or other chemical hazards
   • None of the above
   Note: If you are potentially exposed to any of these hazards, you must complete appropriate EHS training before beginning such work. Check training requirements at https://ehs.mit.edu/site/training

4. Are you allergic to either of the following?

   • Animals: No Yes: Please describe which animal and nature of allergic reaction:
   • Latex: No Yes: Please describe nature of allergic reaction:

5. Please indicate your status for Hepatitis B virus and Tetanus vaccines

   Hepatitis B virus:

   • Vaccinated Year completed if known:
   • Not vaccinated
   • Unknown/other
     Explain:

   Tetanus toxoid:

   • Vaccinated Year completed:
   • Unknown/other
     Explain:
   Note: It is recommended that all adults have a booster for tetanus/diphtheria/pertussis [TDaP] every 10 years and consider a hepatitis B vaccine series as part of their health care maintenance. These vaccinations are offered through your private medical insurance or through the Employee Health and Occupational Medicine service at MIT Medical. There is no charge for these vaccinations if given as part of MIT's work-related preventative program.

6. Please indicate below which of the following Tuberculosis (TB) screening tests you have had:

   • PPD (skin test) Year completed if known:
   • Chest X-ray Year completed if known:
   • TB blood test (IGRA) Year completed if known:
   • None or unknown

   If you have had a Tuberculosis screening test (either skin test, blood test, and/or chest xray) indicate the test results below:

   • Negative
   • Positive/unknown Please schedule an appointment to review your health status with EHOM at MIT Medical: 617-253-8552
   • Other
     Explain:
   Please note: If you have contact with non-human primates or their tissues and body fluids you will be automatically enrolled in the screening program for tuberculosis and be informed of the risk from Simian B virus.

7. Do you have any medical condition (such as pregnancy or immunosuppression related to infectious disease or chemotherapy) which could increase your health risk or concern about contact with laboratory animals or hazardous materials that will be used in your work?

   • No
   • Yes: Please schedule an appointment to review your health status with EHOM at MIT Medical: 617-253-8552

8. Do you have any ethical concerns pertaining to the care or use of animals in research that you would like to bring to our attention for follow up?

   • No Yes: Please describe your concerns:

9. Do you have any concerns regarding your emotional well-being that you believe may be intensified by working with research animals?

   • No Yes: Please describe your concerns:

10. If you think you may be developing a work-related illness (like animal or latex allergy), or have any ethical or emotional concerns pertaining to the care or use of animals in research, please make a medical appointment for a free and confidential consultation with the EHOM Medicine clinical staff: 617-253-8552.

    Having your occupational health issues addressed is important and such activity is required to be reported annually, without any identifying information, on the CAC protocol renewal forms (see Occupational Health Section on CAC forms).

    Also note that using a respirator at work does require an evaluation by MIT Medical and then fit testing by EHS.

    • Check here to acknowledge that you have read the preceding to complete this questionnaire

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If you have completed a printed version of this Questionnaire, please send via mail to: Jackie Sherry, RN, CS, E23-135.
Thank you!