EMPLOYEE HEALTH OFFICE – OCCUPATIONAL HEALTH PROGRAM QUESTIONNAIRE

SECTION A - ANNUAL UPDATE

Have you previously completed this form and are currently enrolled in the Occupational Health Program?

Yes

No

I hereby give permission to the University of Miami Employee Health Office (“UM EHO”) and its designated provider (hereinafter referred to as “Provider”), to provide the following job-related health-care services: physical examination, immunizations, audiometry, medical evaluation for use of a respirator, blood collection and laboratory testing, and other healthcare services as may be deemed professionally necessary based on the nature, intensity and frequency of my exposure to hazards associated with biological, human, and animal research. I understand that my blood may be collected, examined and/or stored if deemed necessary based on the substantial likelihood of an occupationally acquired infection with an agent. Additionally, I understand that in the event of an occupational illness, injury or other adverse event it may be medically necessary for the UM EHO, as well as the Provider, to have access to any relevant medical health records. Further, I understand that such events may also require the disclosure of necessary medical information by the UM EHO and/or the Provider to persons with a need to know, including supervisory personnel and other University of Miami administrators who may need to know this information in order to implement work restrictions for the protection of my health and/or the health of others. REVOCATION: To effectively revoke this consent, I must deliver written notice of revocation to the University of Miami Employee Health Office. Such revocation will not apply retroactively and will be effective from the date received by the UM Employee Health Office. WARNING TO EMPLOYEES THAT ARE IMMUNO-COMPROMISED: The administration of live vaccines and/or exposure to job related hazards may be harmful to you. It is your responsibility as the EMPLOYEE to inform your EMPLOYER of any health factors that you believe may adversely affect your health, such as live vaccines and work-related contact with animals.*

CONSENT: I agree with the statement above

VACCINATION HISTORY

Select the appropriate box. Please provide proof of vaccination to ohp@miami.edu. Employee Health can provide assistance if needed.

Hepatitis B*

No

Yes - specify when

Date of Vaccination

Hepatitis A*

No

Yes - specify when

Date of Vaccination

MMR*

No

Yes - specify when

Date of Vaccination

Rabies*

No

Yes - specify when

Date of Vaccination

Tetanus*

No

Yes - specify when

Date of Vaccination

Tb skin test / screening*

No

Yes - specify when

Date of Vaccination

Other vaccines?*

No

Yes - Specify below

Other

Date of Vaccination

Other

Date of Vaccination

Other

Date of Vaccination

In the last year, has your position within the university required you to take on new responsibilities with another lab or another PI?

Yes

No

I hereby give permission to the University of Miami Employee Health Office (“UM EHO”) and its designated provider (hereinafter referred to as “Provider”), to provide the following job-related health-care services: physical examination, immunizations, audiometry, medical evaluation for use of a respirator, blood collection and laboratory testing, and other healthcare services as may be deemed professionally necessary based on the nature, intensity and frequency of my exposure to hazards associated with biological, human, and animal research. I understand that my blood may be collected, examined and/or stored if deemed necessary based on the substantial likelihood of an occupationally acquired infection with an agent. Additionally, I understand that in the event of an occupational illness, injury or other adverse event it may be medically necessary for the UM EHO, as well as the Provider, to have access to any relevant medical health records. Further, I understand that such events may also require the disclosure of necessary medical information by the UM EHO and/or the Provider to persons with a need to know, including supervisory personnel and other University of Miami administrators who may need to know this information in order to implement work restrictions for the protection of my health and/or the health of others. REVOCATION: To effectively revoke this consent, I must deliver written notice of revocation to the University of Miami Employee Health Office. Such revocation will not apply retroactively and will be effective from the date received by the UM Employee Health Office. WARNING TO EMPLOYEES THAT ARE IMMUNO-COMPROMISED: The administration of live vaccines and/or exposure to job related hazards may be harmful to you. It is your responsibility as the EMPLOYEE to inform your EMPLOYER of any health factors that you believe may adversely affect your health, such as live vaccines and work-related contact with animals.*

CONSENT: I agree with the statement above

Have there Been changes to any of the following in the past 12 months?

Job Duties

Yes

No

Personal health

Yes

No

Animal Species you work with

Yes

No

Developed new allergy signs or symptoms

Yes

No

Infectious / biological / chemical agents you work with

Yes

No

I am confirming that there have been no changes to any of the above and I can skip updates on specific hazards.

Yes

No

SECTION B - WORK WITH LIVE ANIMALS

Are you currently working or planning to work with live animals?

Yes - Specify below

No - skip to Section C

Species

Transgenic / GMO

Yes

No

Allergies to Animals?

Yes

No

Work Activities

Select

Frequency of Current Exposure

Select

Exposure Time (in Hours per Day)

Experience Working with Animals (Months/Years)

Symptoms made worse by animal work environment?

Select

Species

Transgenic / GMO

Yes

No

Allergies to Animal

Yes

No

Work Activites

Select

Frequency of Current Exposure

Select

Exposure Time (in Hours per Day)

Experience Working with Animals (Months/Years)

Symptoms made worse by animal work environment

Select

Species

Transgenic / GMO

Yes

No

Allergies to Animal

Yes

No

Work Activities

Select

Frequency of Current Exposure

Select

Exposure Time (in Hours per Day)

Experience Working with Animals (Months/Years)

Symptoms made worse by animal work environment

Select

Do you take any over-the-counter or prescription medication for these symptoms?

Yes – specify below

No

List medications:

Do you have a history of asthma?

Yes

No

Do you have a history of hay fever?

Yes

No

Have you ever had a skin test performed to determine what your allergies are?

Yes - specify below

No

If yes, what was the result:

Have you ever had a blood test performed to determine what your allergies are?

Yes - specify below

No

If yes, what was the result:

Are you now, or have you ever been a cigarette smoker (one or more per week)?

Yes - specify below

No

How many cigarettes / day?

For how many years?

Are you regularly exposed to animals away from work?

Yes - specify below

No

List species:

Do you have any allergic symptoms to these pets?

Yes - specify below

No

What were the symptoms?

SECTION C - WORK WITH BIOLOGICAL / INFECTIOUS MATERIAL

Are you currently working or planning to work with biological and/or infectious materials?

Yes - specify below

No - skip to Section D

Do you currently work or plan to work with microorganisms?

Yes - specify below

No

Choose Type

Select

List examples (i.e., E. coli, Influenza Virus)

Choose Type

Select

List examples (i.e., E. coli, Influenza Virus)

Choose Type

Select

List examples (i.e., E. coli, Influenza Virus)

Do you currently work or plan to work with human source material?

Yes - specify below

No

Choose Type

Select

List examples (i.e., HEK 293T cells, epidermal tissue, feces, saliva)

Choose Type

Select

List examples (i.e., HEK 293T cells, epidermal tissue, feces, saliva)

Choose Type

Select

List examples (i.e., HEK 293T cells, epidermal tissue, feces, saliva)

Do you currently work or plan to work with animal source material?

Yes - specify below

No

Choose Type

Select

List examples (i.e., BHK cells, epidermal tissue, feces, saliva)

Choose Type

Select

List examples (i.e., BHK cells, epidermal tissue, feces, saliva)

Choose Type

Select

List examples (i.e., BHK cells, epidermal tissue, feces, saliva)

Do you currently work or plan to work with plants?

Yes - specify below

No

List species:

Do you currently work or plan to work with biological toxins?

Yes - specify below

No

List biological toxins:

Do you currently work or plan to work with prions?

Yes – specify below

No

List prions:

Do you currently work or plan to work with recombinant and/or synthetic nucleic acid molecules?

Yes – specify below

No

List recombinant and/or synthetic nucleic acid molecules:

SECTION D - ADDITIONAL INFORMATION

To provide context to your previous answers, please list your duties related to the research environment or what biologically related activities you may encounter prompting your enrollment.*

Are you required to use respiratory protection at work?*

Yes – specify below

No

Have you been fit tested within the last 12 months for wearing a respirator*

Yes

No

Do you have any health or workplace concerns?*

If you’re pregnant or planning a pregnancy, or are immunocompromised, please contact the Employee Health Office at ohp@miami.edu for further assessment and guidance.*

I Acknowledge

Not Applicable

Disclaimer: Certain medical conditions may increase the potential risk of health problems when working with animals and/or biological materials. These conditions could include but are not limited to allergies and/or animal dander, asthma, heart valve disease, and immunosuppression.

Write your full name to acknowledge the disclaimer and verify that the information above is correct to the best of your knowledge.*

Please find the required training information below:

UHealth OSHA's Bloodborne Pathogens, Biomedical Waste, Latex Allergy, and TB Training:

For employees – Complete on ULEARN
For students – Complete on BLACKBOARD
Visitors – Contact Employee Health at OHP@miami.edu for external training information.

Zoonotic Training:

For RSMAS employees and students, please upload a Zoonotic Training Certificate (email IACUC at IACUCsupport@miami.edu for your training certificate).

For questions, please contact the Employee Health Office at 305-243-3267 or email us at OHP@miami.edu.