ANIMAL WORK RISK ASSESSMENT FORM
This questionnaire will only be used for purpose of assessing fitness to work with animals in the lab or field setting. The questionnaire is secured and meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected copy of the filled questionnaire will be emailed to you for printing to bring to clinic.
Name (according to NRIC/FIN)
*
Job Designation
NRIC/FIN (last 4 characters only)
Staff / Student Number (NUS only)
Department, Institution
Email (Please fill in Correctly)
*
example@example.com
Any Drug/Other Allergies
No
Yes. Please indicate:
Type of Medical Evaluation
Pre-Employment
Pre-placement
Periodic (Submitted Form previously)
Requested
Exit
What Biosafety Level Lab will you be working in?
ABSL2
ABSL3
ABSL1
Other
Lab Animal Use
I am not on an approved animal use protocol and will not be working in areas where animals are housed or transported. (Please proceed to the end of questionnaire)
I am on an approved animal use protocol, but will not be handling animals, animal tissues or cell lines, or working in areas where animals are housed or transported.
I am on an approved animal use protocol and working with animals.
I am not on an approved animal use protocol and working with animals / animal tissues.
I am not handling animals, but will be working in areas where animals (excluding non-human primates) are housed, or transported.
I am not handling animals, but will be working in areas where animals (including non-human primates) are housed or transported.
I will be involved with veterinary care or animal husbandry.
I am working with human specimens cells, body fluids, etc in conjunction with animal studies.
I am not on approved animal protocol, not handling animals and not working in areas where animals are housed or transported.
Indicate Type of Animals Handled in Lab/Animal Facility Worked in
Rows
More than 3x/week
1-3x/week
1-3x per month
Rare
Rodent (eg mouse, rat, guinea pig)
Rabbits
Pigs
Pig tissue/sample only
Goats
Sheep
Non-Human Primates
Maque derived tissue/sample
Bats
Bat tissue/sample only
Cats
Dogs
Marine vertebrates (eg fish)
Marine invertebrates (eg crabs)
Reptiles
Frogs
Tree Shrews
Birds eg chickens
Insects
Others
If OTHER ANIMALS, please list here:
What other lab hazards are you exposed to?
lonising Radiation
Lasers
Hazardous chemicals (eg corrosives, carcinogens, toxics)
Human specimens such as blood, tissues, other body fluids
Biological infectious agents eg viruses, bacteria, fungi Specify:
Do you have the following medical conditions?
Rows
No
Yes
Elaborate
Dr Comments
Work or Animal related work injury/disease
Tuberculosis or close contact with TB patient
Diabetes mellitus
Autoimmune disease eg SLE, Rheumatoid arthritis
Cancer
Chronic viral infections (eg Hepatitis B, C, HIV)
Congenital conditions resulting in immunodeficiency
Chronic steroid or immunosuppressive drug use
Chronic lung condition eg asthma, pneumothorax
Chronic disorder of blood cells
Environmental allergies
Latex allergies
Eye or visual problems
Deafness or ringing in ear
Heart diseases
Frequent neck, arm, back pain
Fainting or fits/epilepsy
Paralysis, muscle weakness or numbness
Past history of Measles
Allergy to animals
Eczema
Hand dermatitis
Shortness of breath at work
Lived in other countries other than Singapore. Please list:
COVID infection. Please indicate date:
Musculoskeletal conditions
Smoker
Take alcohol drinks 3 times or more per week
No regular exercise more than 2 times per week
On medication for medical condition
On regular supplements
Any other medical condition that is not listed in the above
Currently pregnant or planning pregnancy in next 3 months (female only)
What vaccinations have you taken? Please key in the dates in the next section
Tetanus/Tdap (Tetanus+Diptheria+Pertussis)
Hepatitis B
Influenza
Hepatitis A
COVID
Rabies
Q Fever
Meningococcal
MMR (Measles+Mumps+Rubella)
Chickenpox
Others
I do not have any of the mentioned vaccinations or have any documentation
Date of Tetanus/Tdap vaccination (please put NA if did not take/can't remember)
*
Date of Flu vaccination (please put NA if did not take/can't remember)
*
Details and Dates of vaccinations that you have taken
Date and Results of Hepatitis B screen (HBsAg) and antibody titres (IU/L)
Date of most recent Chest Xray or Tuberculin Skin Test or Quantiferon Test for TB
/
Month
/
Day
Year
Date
Do you need to use N95 respirator regularly (more than 3 days per week)?
Yes
No
Declaration
I declare that I have answered this form truthfully and to the best of my knowledge. I understand that my institution at its discretion can choose not to bear costs of any future illness or treatment should there be false or incomplete declaration of the above.
I consent for the relevant information to be conveyed to my Supervisor or Department or other departments where relevant.
I consent to the release of my medical details to the treating clinic/hospital/doctor(s) concerned in the event of an incident or where deemed necessary.
Applicant Name & Signature
*
Date of Submission
*
/
Day
/
Month
Year
Date
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TO BE FILLED BY CLINIC ONLY
Height (m)
Weight (kg)
Visual Acuity
Rows
Satisfactory
Abnormal
Right - Far Uncorrected
Left - Far Uncorrected
Right - Far Corrected
Left - Far Corrected
Blood Pressure (mmHg)
Pulse Rate (BPM)
Hep B screen
Not immune/tested
Immune. Titres:
Systemic Review
Rows
Normal
Abnormal
Notes on abnormalities
Eyes
ENT
Cardiovascular
Respiratory
Neurological
GIT
Musculoskeletal
Pyschiatric
Others
Consultation Notes (if any)
Date of Consultation (if any)
-
Day
-
Month
Year
Date
CERTIFICATE OF FITNESS
The Occupational and Diving Medicine Centre. 20 Lower Kent Ridge Road Singapore 119080
This clinical evaluation was designed to meet the recommended guidelines for
Animal Research
.
Type of Animals Approved for Use
RODENT
RABBIT
PIG
PIG TISSUE/SAMPLE ONLY
GOAT
SHEEP
NON-HUMAN PRIMATES
MACAQUE DERIVED TISSUE/SAMPLE
BAT
BAT TISSUE/SAMPLE ONLY
DOG
MARINE VERTEBRATES
MARINE INVERTEBRATES
REPTILES
FROG
TREE SHREW
BIRD
ALL ANIMALS IN COMPARATIVE MEDICINE
ALL ANIMALS
NOT HANDLING ANIMALS OR WORKING IN ANIMAL FACILITY. IN APPROVED ANIMAL PROTOCOL ONLY.
NOT HANDLING ANIMALS. WORK IN ANIMAL FACILITY ONLY.
NOT HANDLING ANIMALS. INSPECTION OF ANIMAL FACILITIES IN COMPARATIVE MEDICINE INCLUDING NON-HUMAN PRIMATE FACILITY.
NOT HANDLING ANIMALS. INSPECTION OF ANIMAL FACILITIES IN COMPARATIVE MEDICINE EXCLUDING NON-HUMAN PRIMATE FACILITY.
ABSL3 FACILITY
INSECTS
ABSL2 FACILITY
NOT HANDLING ANIMALS. OBSERVATION IN ANIMAL FACILITY (EXCLUDING NON-HUMAN PRIMATES) ONLY.
HANDLING ANIMALS IN ASTAR BIOLOGICAL RESOURCE CENTRE ABSL2
NOT ON APPROVED ANIMAL USE PROTOCOL AND NOT WORKING IN ANIMAL FACILITIES. PRINCIPAL INVESTIGATOR.
NOT ON APPROVED ANIMAL USE PROTOCOL AND NOT WORKING IN ANIMAL FACILITIES.
GOAT TISSUE/SAMPLE
COW TISSUE/SAMPLE
NOT HANDLING ANIMALS. OBSERVATION IN NON-HUMAN PRIMATE FACILITY.
NOT ON APPROVED ANIMAL USE PROTOCOL AND NOT HANDLING ANIMALS. WORK IN ANIMAL FACILITY (NON-NHP).
Other
Outcome of Occupational Health Evaluation
Fit to work
Fit to work with restrictions
Temporary unfit to work
Permanently unfit to work
Restrictions (if any)
Presence of medical condition that can place examinee at increased health risk of performing his work duties
Yes
No
For protection of health and safety of the examinee, the following is recommended:
Tetanus vaccination
Hepatitis B screen/vaccination
Hepatitis A screen/vaccination
MMR (Measles Mumps Rubella) vaccination
Influenza vaccination
Chest Xray
Quantiferon TB Test
Spirometry
Resting ECG
FBC, ESR, GLUCOSE
FBC, ESR, GLUCOSE, LIVER/RENAL FUNCTION
Rabies screen/vaccination
Other
Tetanus vaccine
Not valid. Advise vaccination.
Valid
Date of vaccination
Hepatitis B immunity
Not immune. Advise vaccination.
Immune.
Not required.
Advise Hep B screen and vaccination if not previously done.
Other
FLU VACCINE
Not valid. Advise vaccination.
Valid
Date of vaccination
CHEST XRAY
-
Day
-
Month
Year
Date
Physician Remarks (if any)
Validity
1 year
2 years
3 years
Advise resubmission if there is change in medical status (new medical conditions) or type of lab animals
Other
BSL3 OH Number
Animal OH Number
Dr Gregory Chan, Senior Specialist Occupational Medicine M06367C
Date of Certification
-
Day
-
Month
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Declaration by Applicant
I am aware of the health risks and decline to take the influenza vaccination recommended by the Occupational Health clinic.
Signature of Applicant
Date
-
Day
-
Month
Year
Date
Submit
Should be Empty: