Animal Handlers Form Animal Handlers Form Employee InformationName* First Middle Last Date of Birth* Month Day Year Do you decline to provide your animal handling background information?* No Yes Birthplace* Employer* Employee ID/SSN* Gender* Male Female Home/Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Marital Status*MarriedUnmarriedHome Phone (or cellphone)*Work PhoneAnimal ContactWhat species of animal will you be exposed to in your job? This includes direct contact with animals, animal tissues, carcasses, bone, or excrement and animal enclosures.* Amphibians Birds Cats Dogs Farm Animals Ferrets Fish Guinea Pigs Reptiles Pigs Primates Rabbits Rats or Mice Other Rodents Sheep Wild Animals Other If "other", please describe. What kind of contact will you have?* Direct contact with animals Direct contact with non-fixed or non-sterilized animal tissues, fluid, or wastes Direct contact with non-sanitized animal caging or enclosures Service support to animal equipment, devices, and/or facilities Please describe direct contact with animals (if any) Have you ever had a job working with animals?* Yes No If "yes", what animals have you worked with in the past? Do you have contact with animals outside work?* Yes No If "yes", please list species (type of animal) Medical HistoryDo you have any ongoing medical problems?* Yes No If "yes", please describe Have you had any of the following medical problems?* Pneumonia Heart Disease Diabetes Cancer Seizures Recurrent Bronchitis Liver Disease Rheumatic Fever Kidney Disease Gastrointestinal Disorder Arthritis Tuberculosis Heart Murmur-Valve Disease Loss of Consciousness Chronic Back or Joint Pain Carpal Tunnel Syndrome Tennis Elbow Shoulder Problems None If "yes", please describe Have you been informed by a physician that you have an immune compromising condition or are you taking medication that impairs your immune system (steroids, immunosuppressive drugs, or chemotherapy)?* Yes No Are you currently taking any medications?* Yes No If "yes", please list Have you ever been injured or developed an illness from your work with animals?* Yes No If "yes", please describe Do you have, or have you ever had:* Chronic Cough Hay Fever Asthma Skin Rashes (eczema) Allergies to Food, Pollens, or Dust Allergic Eye Symptoms Natural Parent or Sibling with Allergies to Animals or Their Substances None/N/A Do you have any of the following symptoms that you feel are caused by or made worse by your work with laboratory animals?* Watery, Burning, or Itchy Eyes Runny Nose Sneezing Wheezing Cough Shortness of Breath Chest Tightness Hives Rash None/N/A Do you have allergies to animals or animal products (e.g. fur, wool, feathers, saliva, urine, feces, etc.)?* Yes No If "yes", please list: Do you have an allergy to latex?* Yes No If "yes", please describe: If female, are you pregnant or currently within the childbearing ages?* Yes No If "yes", please describe: Please list any allergies to medications (if none, just enter "N/A"):*Animal-related infection history:* Salmonella Infection Leptospirosis Infection Hantavirus Infection Herpes B Virus Histoplasmosis Allergic Alveolitis (pigeon fancier's lung) Viral Hemorrhagic Fever Ringworm of Other Skin Infection Toxoplasmosis Tularemia Rabies Q Fever Campylobacter Psittacosis Other Animal Infection History None/N/A Please explain any positive answers:Immunization/Infectious Disease HistoryDiphtheria/Tetanus (or Tdap)* Vaccine Illness None Date of Diphtheria/Tetanus Illness or Vaccine: Month Day Year Polio* Vaccine Illness None Date of Polio Illness or Vaccine: Month Day Year Measles* Vaccine Illness None Date of Measles Illness or Vaccine: Month Day Year Mumps* Vaccine Illness None Date of Mumps Illness or Vaccine: Month Day Year Rubella* Vaccine Illness None Date of Rubella Illness or Vaccine: Month Day Year Chicken Pox (varicella)* Vaccine Illness None Date of Chicken Pox Illness or Vaccine: Month Day Year Pneumonia* Vaccine Illness None Date of Pneumonia Illness or Vaccine: Month Day Year Meningitis* Vaccine Illness None Date of Meningitis Illness or Vaccine: Month Day Year Influenza (flu)* Vaccine Illness None Date of Influenza Illness or Vaccine: Month Day Year Typhoid* Vaccine Illness None Date of Typhoid Illness or Vaccine: Month Day Year Rabies* Vaccine Illness None Date of Rabies Illness or Vaccine: Month Day Year Yellow Fever* Vaccine Illness None Date of Yellow Fever Illness or Vaccine: Month Day Year Tuberculosis/TB* Vaccine Illness None Date of Tuberculosis/TB Illness or Vaccine: Month Day Year Chest X-Ray (for TB+)* Yes No Date of Chest X-Ray for TB+: Month Day Year Hepatitis A* Vaccine Illness None Date of Hepatitis A Illness or Vaccine: Month Day Year Hepatitis B* Vaccine Illness None Date of Hepatitis B Illness or Vaccine: Month Day Year Hepatitis C Positive* Yes No Date of Hepatitis C Positive: Month Day Year Other Vaccine: SignatureSignature*Signature Date* Month Day Year
