WTAMU Occupational Health Enrollment
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  • WTAMU

    WTAMU

    Environmental Health and Safety Occupational Health Program Enrollment Form

  • Why am I being asked to complete this enrollment? West Texas A&M University is required by TAMUS, State and Federal regulations to provide an occupational health program for all individuals who may have occupational risk. Please answer the questionnaire in Part I to determine your occupational risk status. If you have questions or need assistance, please contact Academic Research Environmental Health and Safety (AREHS) at (806) 651-2740 or ar-ehs@wtamu.edu

    Helpful hint on mobile devices: you may be able to use microphone to dictate answers. 

  • 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 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)

    • Which of the following best describes your animal exposure at work? (check one below)*
    • Rows
    • Rows
    • Rows
    • Part 3. Health and Respirator Use 
    •  - -
    • 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?*

    • 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 

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      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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