Medium

Available on

Apple Android Windows

Medical History Questionnaire for Employees or Affiliates with Animal Contact Mobile App

Employees working with research animals or entering vivaria are required to complete the Medical History Questionnaire for Employees or Affiliates with Animal Contact mobile app to identify applicable health and safety recommendations. Researchers with indirect animal contact may elect to complete the questionnaire. The purpose of the app is to determine if you have any special health needs to work safely with animals. A common health risk includes allergies or respiratory sensitivities which may be caused or aggravated by work around animals. Chronic health conditions, pregnancy, or immune system deficiencies may increase risk of infection from animals (zoonotic disease) or infectious agents used in animals. Chemical exposure from treated animals may also present additional risks during pregnancy or for certain respiratory or chronic health disorders. Based on your answers, medical recommendations will be provided to reduce risk of undesirable health effects and may include wearing additional personal protective equipment or modifying work procedures.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Medical History Questionnaire for Employees or Affiliates with Animal Contact Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Medical History Questionnaire for Employees / Affiliates with Research Animal Exposure

  • Ico textbox

    Name:

  • Ico date

    Date of Birth :

  • Ico dropdown

    Date of Birth :

  • Ico textbox

    SSN – Last 4 numbers only:

  • Ico multiline

    1. List animals you will be working with:

  • Ico date

    2. Date of last Tetanus vaccine booster:

  • Ico dropdown

    If you will be working with human blood/tissues/cells/cell lines in animals, have you received a...

  • Ico textbox

    No use in animals

  • Ico camera

    If yes: a) List dates and attach vaccination record:

  • Ico date

    b) If post-vaccination titer was done, list date:

  • Ico camera

    Titer result (attach record):

  • Ico checkbox

    Not done

  • Ico statictext

    Do you have any of the following medical conditions?

  • Ico statictext

    Allergy and Respiratory System Health History

  • Ico checkbox

    Asthma or other chronic respiratory disease

  • Ico checkbox

    Asthma or other chronic respiratory disease

  • Ico checkbox

    Allergic skin reactions such as hives, rash, itching.

  • Ico multiline

    If yes, explain:

  • Ico checkbox

    Known or suspected animal allergies.

  • Ico multiline

    If yes, list animal(s):

  • Ico checkbox

    Known or suspected allergies to chemicals, latex, food, or environment

  • Ico multiline

    If yes, please list:

  • Ico checkbox

    Are you currently using respiratory protection or mask?

  • Ico checkbox

    If yes, have you been fit-tested?

  • Ico textbox

    List type of respirator/mask you are using:

  • Ico statictext

    Immune/Metabolic System Health History

  • Ico checkbox

    Chronic health conditions such as diabetes

  • ...and More!

Related Agriculture, Forestry & Fishing Apps... and they're all free for GoCanvas subscribers!

App Name

Risk Assessment Work Evaluation Quest...

The Risk Assessment Work Evaluation Questionnaire for Employees or Affiliates with Animal Contact mobile app is provided t...

App Name

Lab Exit/Renovation/Decommissioning L...

Chemical, biological and radioactive materials are used and stored within designated areas for teaching and research purpo...

App Name

Biological Agent Registration Form

The Biological Agent Registration Form mobile app must be completed by the Principal Investigator (PI) and must be approve...

App Name

Lab Exit/Renovation/Decommissioning ...

Chemical, biological and radioactive materials are used and stored within designated areas for teaching and research purpo...

App Name

Laboratory Sign Request Form

Please use the Laboratory Sign Request Form mobile app to assist in checking the hazards that are associated with your lab...

App Name

PSDS- Applicant (for CSUA Lab Contact...

All proposed handlers of controlled substances (CS) must be 18 years or older and submit a Personal Screening Data Sheet t...

App Name

Statement of Training and Experience ...

Use the Statement of Training and Experience for Radioactive Material Users mobile app with a smartphone or tablet to docu...

App Name

Lab Exit/Renovation/Decommissioning ...

Chemical, biological and radioactive materials are used and stored within designated areas for teaching and research purpo...

More Information


Related Blog Posts