BOHP Occupational Health Enrollment _Accessible 

  • Occupational Health Enrollment 

     

    What is this? Texas A&M University is required by TAMUS, state, and federal regulations to provide an occupational health program for individuals who may have occupational risk of exposure to infectious biohazards or who have contact with animals. The program includes medical review and surveillance.

     

    The purpose of enrolling in the Biosafety Occupational Health Program annually is to evaluate your workplace hazards (e.g. infectious biohazards, animal allergens, etc.), and any new or existing health concerns that may be affected by these hazards. Annual enrollment also provides you an opportunity to request an appointment with the occupational health provider if you wish to discuss any of these concerns confidentially.

     

     If you have questions or require assistance, you may contact the medical provider directly at (979) 393-0161 or info@uohpartners.com

     

     Helpful hint: Mobile devices may be able to use device microphone to dictate answers.

  • Today's Date:*
     - - :
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Job (check all that apply)*

    • Work Environment 
    • BSL and toxins (check all that apply)
    • Do you work with or are you potentially exposed to high consequence pathogens? (check all that apply)
    • Do you work with or are you potentially exposed to human or non-human primate blood or other potentially infectious materials (OPIM)? (OPIM examples below)*

    • Other potentially infectious materials (OPIM) in humans or non-human primates:

      • All body fluids where it is difficult or impossible to differentiate between body fluids
      • Amniotic fluid
      • Any body fluid visibly contaminated with blood
      • Any unfixed tissue or organ (other than intact skin) from a human or non-human primate (living or dead) 
      • Blood, organs, or other tissues from experimental animals infected with bloodborne pathogens
      • Cell, tissue, or organ cultures 
      • Cerebral spinal fluid
      • Culture media or other solutions containing bloodborne pathogens
      • Pericardial fluid
      • Peritoneal fluid
      • Pleural fluid
      • Saliva in dental procedures (whether or not there is visible blood present)
      • Semen
      • Synovial fluid
      • Vaginal secretions
    • Do you work with or are you potentially exposed to unfixed specimens of brain or nerve tissue from mammals?*
    • Do you work with or are you potentially exposed to Lentiviral vectors?*

    • This is to advise you that if you are accidentally exposed (needlestick, cut, mucous membrane splash), antiviral medication prophylaxis may be recommended ASAP.   Please report any potential exposure to your manager and TAMU Biosafety without delay.

    • Do you work with or are you potentially exposed to the following hazards? (check all that apply)
    • Do you know who to contact regarding workspace ergonomics and field safety?

    • After completing this form, you will receive an email with information on how you can contact EHS should a need arise. (You may need to check your spam/junk folder)

    • Exposure to Animals 
    • Which of the following best describes your animal exposure at work? (check one below)*
    • Rows
    • Rows
    • Rows
    • Vaccinations 
    • Current Date for Tetanus
       - -
    • If applicable, check below:

    • ->RECOMMENDATION:  You are overdue for Tetanus vaccination

    • --RECOMMENDATION: Tetanus vaccination is recommended every 10 years.

    • If applicable, check below:

    • --RECOMMENDATION: The reviewer will determine if Hepatitis B vaccine is recommended for work

    • If applicable, check below:

    • --RECOMMENDATION:  The reviewer will advise regarding eligibility for Rabies vaccine after review of your animal work.

    • Do you plan to travel internationally for WORK in the next year?

    • --RECOMMENDATION:  A free Travel Health report can be obtained from info@uohpartners.com upon request.

    • In addition to the vaccines you have had, do you need any of the following vaccinations for work?*

    • Allergies or Asthma 
    • Do you have animal allergies?*

    • After completing this form, you will receive an email with information on Laboratory Animal Allergy Prevention.  (You may need to check your spam/junk folder)

    • Are you allergic to any of the animals with which you will be working?*
    • Select the animals to which you are allergic.*

    • Select the symptoms you experience.*

    • Do you have environmental allergies?*
    • Select your environmental allergy triggers.*

    • Select the symptoms you experience.*

    • Do you have asthma?*
    • Do you experience shortness of breath or wheezing related to work?*
    • Select your asthma triggers.
    • Respirator use 
    • Are you required or do you wish to wear respiratory protection at work?*
    • What type of respirator? (check all that apply)*

    • Have you been medically cleared to wear a respirator?*
    • Immunity and Health Restrictions 
    • Do you have a medical condition that impairs your immune function (decreases ability to fight infections)?*
    • Do you take medication that significantly impairs your immune function? (eg. high-dose corticosteroids, chemotherapy, organ transplant medication, TNF inhibitors or autoimmune treatment)*
    • Have you discussed your work environment with your personal physician?*
    • Do you have recurring fevers or an unexplained chronic febrile illness?*
    • Do you have any rashes, sores, or skin conditions on your exposed skin (arms, hands, head, face, neck)?
    • Are you pregnant (female) or planning pregnancy (female or male partner)?
    • Have you discussed your work environment with your personal or obstetric physician?*
    • Would you like to discuss potential reproductive hazards in your work environment? Do you have concern about reproductive hazards related to workplace exposure to anesthetic gases?

    • After completing this form, you will receive an email with information about reproductive hazards related to workplace exposure. (You may need to check your spam/junk folder)

    • Do you have a serious health condition that may affect your ability or safety at work?*
    • Do you have any medical restrictions (from a doctor or self-imposed)?*
    • Finish and Sign 
    • Do you have any specific unanswered workplace health concerns? (eg. regarding your personal health and any potential exposure(s) you may have to infectious biohazards or animals at work?*

    • Consent: "I consent to send this information to Biosafety and the Occupational Health Physician (UOHP)."

      Certification: "I have completed this questionnaire to the best of my knowledge for medical clearance and the occupational health program requirements."

      Please review consent and certification. Sign your name by typing and press "Submit" below. For questions, comments, or concerns please contact: University Occupational Health Partners, phone (979) 393-0161 or info@uohpartners.com 

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