Risk Assessment Screening Questionnaire (RASQ):

For All Individuals with Vertebrate Animal Exposure

All individuals at Cal Poly Pomona who have contact with, or are in close proximity to University animals are required to complete this self-assessment questionnaire. This policy applies at minimum to individuals involved in classroom instruction, who conduct research investigations, or work around animal facilities. The Institutional Animal Care and Use Committee (IACUC) and Environmental Health & Safety (EH&S) at Cal Poly Pomona want you to be safe and protected in such situations.


**PLEASE NOTE: Starting in the Fall 2024 semester, students enrolled in academic coursework involving work with or in close proximity to animals will no longer be required to complete the RASQ. Instead, students must complete the Risk Acknowledgment form online via CPP Learning: Environmental Health & Safety Risk Acknowledgment, or submit a hard copy to their instructor: Animal Work Risk Acknowledgment Form.


Vaccinations:

The occupational health physician at the Cal Poly Pomona Student Health Center recommends tetanus vaccination for all animal users, given as Tdap (tetanus, diphtheria, and acellular pertussis (whooping cough)). Rabies and other vaccinations may be warranted in some situations. Discuss this with your personal health provider. You may wish to note it on the RASQ or HHQ.


Please read each question and assess your perceived exposure to animals. If you have questions about this assessment or need assistance, please contact Lance Coey, Biosafety Officer, EH&S, at email lwcoey@cpp.edu or phone 909-869-5054.

Please provide your full name.

Select
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Briefly describe animal user type.

*Note: If you are a student working on a research project, please change your Animal User Type to "Research Personnel"

Select
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Briefly describe specific animal use.

General setting of animal encounter.

Select
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Briefly describe the setting of animal encounter.

Select or enter value
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Briefly describe anticipated animal handling.

(check all that apply)

Animal Sensitive Medical Conditions:*

Please indicate below if you have any of the following medical conditions:

  • known or suspected allergies to animals
  • lung problems
  • chronic health problems such as diabetes
  • renal or liver disease
  • sickle cell disease
  • valvular heart disease
  • immune system deficiencies or other limitations to your ability to fight off disease
  • current therapy with high dose steroids, radiation therapy or cancer therapies
  • history of problems with your spleen or absence of your spleen
  • pregnant or planning to get pregnant
Physician Consultation:*

Would you like to complete a Health History Questionnaire (HHQ) and consult with a physician prior to working with animals?

By printing my name below and submitting this form electronically, I am indicating that I am aware of the risks associated with using animals, I am submitting this information truthfully and willingly, and I will submit a Health History Questionnaire if required to do so.


Printed Name:

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