BIOSAFETY RISK ASSESSMENT FORM

BIOSAFETY RISK ASSESSMENT FORM

The Occupational and Diving Medicine Centre / NUS OH Clinic

This questionnaire will only be used for purpose of assessing fitness to work with biological agents. The questionnaire meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected copy of filled questionnaire will be emailed to you to print and bring down to clinic.
Name (according to NRIC/FIN/ID)*
Job Designation
NRIC/FIN (last 4 characters)
Staff / Student Number (NUS only)
Department, Institution
Email*
example@example.com
Pre-employmentPre-placementPeriodicExitRequested
BSL2BSL3BSL2+Other
List the Biological Agents that you will be working with
Cell cultureCell culture of virus infected cellsProcessing of human tissuesProcessing of animal tissuesHandling Hepatitis B or C viruses and liver toxic materials like AflatoxinsFor BSL3 lab - it is a mixed pathogen lab
lonising RadiationLasersHazardous chemicals (eg corrosives, carcinogens, toxics)Lab Animals or its tissuesHuman specimens eg blood, tissues, other body fluids

Do you have the following medical conditions?

Rows	No	Yes	Elaborate	Dr Comments
Work related injury/disease
Tuberculosis or close contact with TB patient
Diabetes mellitus
Autoimmune disease eg SLE, Rheumatoid arthritis
Cancer
Chronic viral infection (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
Heart disease
Frequent neck, arm, back pain
Giddiness or loss of balance
Fainting or fits/epilepsy
Paralysis, muscle weakness or numbness
Currently pregnant or planning in next 6 months
Musculoskeletal conditions
COVID Infection

I smokeI drink alcohol regularlyI exercise regularly at least twice a week.I do not exercise regularly
TetanusTdap (Tetanus+Diptheria+Pertussis)Hepatitis BInfluenzaHepatitis ACOVIDRabiesQ FeverMeningococcalMMR (Measles+Mumps+Rubella)ChickenpoxI do not have any of the mentioned vaccinationsOther vaccines. Please specify:
Details and Dates of vaccinations that you have taken
Date and Results of previous Hepatitis B screen (HBsAg) and titre value (IU/L)

Assessing Allergy and Asthma. Do you have the following?

Please elaborate any YES answers
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.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
Student/Staff Signature (please sign appropriately)*

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Date of Submission*

DayMonthYear
Date
File Upload

Cancelof
TO BE FILLED BY CLINIC ONLY
Height (m)
Weight (kg)
BMI
Blood Pressure (mmHg)
Pulse Rate (BPM)

Physician Remarks
Date of Consultation

DayMonthYear
Date
CERTIFICATION OF FITNESS
Fit to work with no restrictionsFit to work with restrictionsTemporary unfit to workPermanently unfit to workFit for Exit BSL3 LabFit to work with wastewater samplesFit to work in BSL2, ABSL2, BSL3, ABSL3Fit for Visiting Entry to BSL3 LaboratoryFit for Inspection of BSL3 LaboratoryOther
YesNo
Hepatitis B screen/vaccinationCOVID vaccinationInfluenza vaccinationFull blood count, ESR, glucoseLiver/Renal functionChest XrayQuantiferon TB TestTuberculin Skin TestPneumococcal vaccinationJapanese Encephalitis vaccinationRabies screen/vaccinationLiver functionKidney functionHepatitis A screen/vaccinationPoliomylelitis vaccinationTyphoid vaccinationTetanus vaccinationTetanus, Pertussis, Diptheria vaccinationMeningococcal vaccinationMalaria ParasiteCan consider Jynneos Smallpox vaccine (if working with MPox)Resting ElectrocardiogramOther
Not immune. Advised vaccination.Not screened. Advised screening/vaccination.Immune.Titres:
Not immune. Advised vaccination.Not screened. Advised screening/vaccination.Immune.Titres:
Not immune. Advised vaccination.Not screened. Advised screening/vaccination.Immune.Titres:
Not valid. Advised vaccination.ValidDate
Physician Remarks
Mask Fitted for
BSL OH Number
1 year2 years3 yearsWhen there's change in health statusNot Applicable5 yearsOther
Dr Gregory Chan, Signature

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Date

DayMonthYear
Date
Time

Hour Minutes

AM/PM Option
Should be Empty:

CERTIFICATION OF FITNESS