TAMUSA Occupational Health Enrollment

  • Texas A&M University - San Antonio

    Occupational Health Medical Enrollment

  • Why am I being asked to complete this enrollment?
    The Occupational Health Program (OHP) at TAMUSA supports employees and students that work with animals, biological materials, and other potential hazards.  OHP promotes health and safety by identifying and mitigating risks through education, prevention, medical screening, and monitoring. 

    Please complete this secure enrollment form. 

    • Enrollment is valid for one year and is required for employees and eligible students including those who work with animals or are listed in an IACUC or IBC protocol.
    • The University recommends that enrollees update this information any time they change jobs, perform new work activities, or experience a change in health status.
    • If you have questions about this form or OHP enrollment, contact  IBC@Tamusa.edu.
    • If you have questions or require assistance, you may also contact the Occupational Medicine provider directly at (979) 393-0161 or info@uohpartners.com
    • HELPFUL HINT: on mobile devices: you may be able to use microphone to dictate answers.
  • Today's Date:*
     - - :
  • Format: (000) 000-0000.
  • Job (check all that apply)*

  • Are you paid for your work in this position?
    • Part 1. Animal, Pathogen, Human/primate, Hazards 

    • Please check ALL that apply:

    • Required double check. Choose one below.*
    • Part 2. 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)

    • Part 3. Health and Respirator Use 
    • 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

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

    • 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.
    • 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?*
    • 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)?
    • 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)?*
    • 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?*
    • Part 4. Signature 

    •  

      Please certify by signing that you have completed this form to the best of your knowledge for review by the Occupational Medicine provider. Then complete by pressing SUBMIT.

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