Occupational Health Services 480 Oak Rd, Stanford, CA 94305 T 650.725.5308 F 650.725.9218

Dear Researchers,

Do you have:

Red, itchy eyes, a runny nose, asthma, or skin rashes? A history of allergies, including allergies to animals, latex, medication, foods or seasonal pollens and grasses? A health status that reduces the activity of your immune system, including pregnancy, any

immunodeficiency, or the use of medications that alter or suppress the immune system?

Working in close proximity to animals may induce or worsen animal allergies, and a history of allergies or an

altered health status puts you at an increased risk for developing animal allergies.

Anyone working directly with vertebrate animals and those that work in animal housing areas are at risk for the

above issues. Animal dander, bedding, cages, food, and even bites and scratches also pose exposure risk.

What can you do?

It is important that you enroll in the medical surveillance portion of Stanford Environmental Health and Safety’s

(EH&S) Laboratory Animal Occupational Health Program (LAOHP).

It’s easy to register—complete and submit this LAOHP Health Questionnaire. This questionnaire covers

common health issues, including your risk of animal allergies.

If you are experiencing allergic symptoms or asthma that you believe relate to your work exposure at Stanford,

please call the Stanford University Occupational Health Center (SUOHC) at 650-725-5308 to schedule an in-clinic

consultation.

Enrollment in this program, consultation with the SUOHC, and implementation of physician recommendations

can help prevent the development or worsening of allergy symptoms. It will also help Stanford assess risk

factors and exposure profiles in order to improve the LAOHP program.

Your confidential information will be reviewed by the Stanford University Occupational Health Center (SUOHC)

at no cost to you or your laboratory. The SUOHC will contact you if they recommend additional medical

evaluation—this may include medical screening or discussion of personal protective equipment (PPE) that will

help prevent or reduce allergy symptoms.

NOTE: If you have previously submitted this questionnaire but have since had a change in health status,

including any of the items mentioned above, please submit an updated health questionnaire.

Sincerely,

Richard Wittman, M.D.

Medical Director, Stanford University Occupational Health Center

Appendix 4-Laboratory Animal Occupational Health Update

Occupational Health Services 480 Oak Rd, Stanford, CA 94305 T 650.725.5308 F 650.725.9218

Additional Information:

For additional information on LAOHP, or if you have questions about working safely with various laboratory

research animals, please refer to the EH&S LAOHP web site or contact EH&S at 650-723-0448. You can also visit

the Dean of Research website.

This National Institute for Occupational Safety and Health (NIOSH) link provides additional information regarding

ways to reduce your exposure to workplace animal allergens.

A Stanford FAQ on animal allergies is available here.

If you have questions regarding pregnancy and animal allergies or other work place risks, please visit the

Reproductive and Developmental Health Protection Program page for further information, including how to

request a risk assessment.

Occupational Health Services, Laboratory Animal Occupational Health & Safety Program Confidential when completed 480 Oak Rd, Stanford, CA 94305 T 650.725.5308 F 650.725.9218

LAOHP: ANIMAL USE AND ALLERGY QUESTIONNAIRE

Name (Last, First, MI) Employee ID# Hire Date

Job Title Work Phone E - mail

Department PI/Supervisor’s Name PI/Phone Number

This form will be reviewed by a health care professional and kept in your confidential medical record at SUOHC. To

maintain your confidentiality, your PI/supervisor must not look at or review your answers to Part B. You may mail or

bring the completed form to SUOHC at the address below, or FAX it to 650-725-9218.

PART A: OCCUPATIONAL EXPOSURE (Your PI/Supervisor may help you complete this page)

My work will NOT include exposure to animals, unfixed tissues, cells, or body fluids.

My work includes the following: (check all that apply)

Direct contact with animals used in research or teaching

Work in the same room as animals but without direct animal handling or contact

Work with unfixed tissues, cells, or body fluids in research or teaching

Providing routine care for animals used in research or teaching

Ongoing field study with _________________ (species) in __________________ (location, Country)

Please mark Yes/No for each animal species:

ANIMAL SPECIES Yes No

Non-human Primates (NHP) Squirrel Monkeys Macaques Work only with NHP tissue1

Sheep (Female/Neonatal) Pigs Goats Bats 1No live NHP contact, only unfixed tissues, cells, body fluids

ANIMAL SPECIES Yes No

Dogs Rabbits Birds Rodents (Domestic/Captive) Sheep (Male) Marine Mammals Fish, Amphibians, or Reptiles Other:

My work also includes potential exposures to (check all that apply):

Bloodborne pathogens: Human tissues, cells, blood or other potentially infectious material

Infectious agents: APB Protocol number(s): ________________________________

Other occupational hazards:

Please describe and list any exposures of concern:

Occupational Health Services, Laboratory Animal Occupational Health & Safety Program Confidential when completed 480 Oak Rd, Stanford, CA 94305 T 650.725.5308 F 650.725.9218

Name (Last, First, MI)

PART B: HEALTH HISTORY (Your PI/Supervisor should not see this page)

Yes No Don’t know

Do you have any allergies or asthma?

If NO, contact SUOHC if you have concerns about work-related allergy, asthma, or other health issues If YES, what triggers your symptoms? What symptoms do you get?

Pollens or plants Skin rash or hives Animals ____________________ Watery or itchy or red eyes

Something at work Runny nose or sinus congestion

Foods Wheezing or chest tightness Medications Shortness of breath or difficulty breathing Latex Other (specify): I’m not sure

Please describe

Yes No Comments

Do you experience allergic symptoms when others work with animals near your work area?

Are your allergy symptoms worsening?

Do you take any medications, nasal sprays, or inhalers for your symptoms?

Do you carry an EpiPen® or similar device?

OTHER HEALTH CONCERNS

Yes No

Do you have any medical conditions (or take any medication) that might suppress your immune system? This includes recent treatment (within 6 months) with chemotherapy or radiotherapy or high-

dose steroids, cancer, rheumatoid arthritis or other autoimmune disorder, and even pregnancy.

Have you been diagnosed with diabetes or told you have an elevated blood sugar level?

Do you have any health concerns that may affect your health at work that you would like to confidentially discuss with an Occupational Health medical provider?

Do you wear a respirator at work?

Yes, a surgical/nuisance dust mask Yes, a fitted N95 or half/full-face respirator/PAPR No, I don’t wear a respirator

If you feel you need to wear a respirator, or if you are due to renew your annual fit testing, contact the EH&S Respiratory Protection Program (723-0448)

I have answered the questions on this form truthfully and to the best of my recollection

_________________________________________ _______________ Signature Today’s Date