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ANIMAL CONTACT HEALTH QUESTIONNAIRE
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1.
NAME
(Required.)
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2.
DATE OF BIRTH
(Required.)
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3.
EMPLOYER
(Required.)
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4.
DEPARTMENT
(Required.)
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5.
Phone you can be reached to discuss this questionnaire
(Required.)
TETANUS IMMUNIZATION
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6.
Have you had a Tetanus/TDaP immunization in the last 10 years?
(Required.)
Yes
No
If not, please contact your employer to discuss where you can obtain a recommended tetanus booster.
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7.
Has anything changed with your health, allergies, or PPE use since you completed your last questionnaire?
(Required.)
Yes
No
I have not previously completed an Animal Contact Questionnaire
OCCUPATIONAL ANIMAL EXPOSURE
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8.
Number of hours you are exposed to cats at work per week.
(Required.)
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9.
Number of hours you are exposed to mice at work per week.
(Required.)
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10.
Number of hours you are exposed to fish at work per week.
(Required.)
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11.
Number of hours you are exposed to rabbits at work per week.
(Required.)
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12.
Number of hours you are exposed to goats at work per week.
(Required.)
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13.
Number of hours you are exposed to rats at work per week.
(Required.)
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14.
Number of hours you are exposed to Guinea pigs at work per week.
(Required.)
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15.
Number of hours you are exposed to sheep (wool) at work per week.
(Required.)
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16.
Number of hours you are exposed to hamsters at work per week.
(Required.)
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17.
Number of hours you are exposed to swine at work per week.
(Required.)
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18.
Other animals and the hours you are exposed to at work per week.
(Required.)
MEDICAL HISTORY
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19.
Have there been any changes in your medical history in the past year? If yes, please list.
(Required.)
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20.
Do you have any ongoing cardiac or pulmonary medical problems that affect your breathing? If yes, please explain.
(Required.)
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21.
Have you been told by a physician that you have an immune-compromising medical condition or are you taking medications that impairs your immune system (i.e. steroids, immunosuppressive drugs or chemotherapy)? If yes, please explain.
(Required.)
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22.
Women: are you pregnant, or plan to become pregnant in the next year?
(Required.)
Yes
No
ALLERGY HISTORY
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23.
DO you have any of the following symptoms / conditions? Check all that apply.
(Required.)
Asthma
Chronic allergies
Chronic cough
Hay fever
Itchy, irritated eyes
Skin rash
None
Please describe:
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24.
Are you allergic to any animals or animal products?
(Required.)
Yes
No
If yes, please list.
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25.
Do you have any other allergies? (i.e., food or medications)
(Required.)
Yes
No
If yes, please list:
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26.
If yes, please describe in detail the reactions you experience when in contact with the things you are allergic to:
(Required.)
*
27.
Are you taking any allergy medication?
(Required.)
Yes
No
If yes, please list medications and frequency:
PERSONAL PROTECTIVE EQUIPMENT
While working with animals, animal tissues, waste, body fluids, and carcasses, or when in animal housing areas, how often do you wear the following personal protective equipment?
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28.
Disposable gloves
(Required.)
Always
Usually
Sometimes
Rarely
Never
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29.
Gown
(Required.)
Always
Usually
Sometimes
Rarely
Never
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30.
Mask
(Required.)
Always
Usually
Sometimes
Rarely
Never
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31.
Cap
(Required.)
Always
Usually
Sometimes
Rarely
Never
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32.
Protective eye wear
(Required.)
Always
Usually
Sometimes
Rarely
Never
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33.
N95 respirator
(Required.)
Always
Usually
Sometimes
Rarely
Never
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34.
Other PPE equipment used.
(Required.)
Always
Usually
Sometimes
Rarely
Never
*
35.
I, the undersigned, hereby authorize Froedtert Health, Inc. and its affiliates (collectively, "Froedtert" or "Workforce Health") to release the results of my medical evaluation, pursuant to the occupational health services performed at the request and expense of my employer or prospective employer as identified above (or their agent) to such employer for the employment-related purposes. Such information may be disclosed in a form or format agreed to between Froedtert and the recipient, which may include disclosure through a designated electronic portal. This authorization included information to be generated and records yet to be created for services provided both before and after the date of my signature. Unless sooner revoked, this authorization expires one year from the date it was signed. I understand that I can revoke the authorization at any time by sending a written note to Froedtert at healthinformation@froedtert.com. However, such revocation will not apply to action already taken in reliance upon the authorization and may impact my ability to continue obtaining occupational health services at the employer's request and expense.
In compliance with HIPPA, Froedtert is conditioning the provision of services on execution of this authorization because the information is being created solely for the purpose of disclosure to the employer. I understand that signing this authorization is voluntary, but failure to do sign will impact my ability to obtain occupational health services at the employer's request and expense and could negatively impact my employment with the employer. I understand the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law. I understand that whether or not I sign or revoke this authorization, Froedtert will continue to be permitted to disclose my protected health information in any manner that is permitted or required by law without mu authorization, including, but not limited to, to my employer, insurer or government agency for workers' compensation purposes, except pursuant to an agreed upon restriction as described in the Joint Notice of Privacy Practice available at https://www.froedtert.com/patients-visitors/patient-privacy/privacy-practices.
Do you consent?
(Required.)
Yes
No
To the best of my knowledge, the information I have provided is true and accurate.
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36.
First and last name.
(Required.)
