Occupational Health form

Please fill out the following form information

Name(Required)

Date(Required)

Application type(Required)

New application

Annual renewal application

Status(Required)

If other, list your home institution and affiliation with NAU

Email(Required)

Local mailing address: Work or residential?(Required)

Department(Required)

Principal Investigator/Employer(Required)

Emergency contact number for project(Required)

Project Title/Protocol #(Required)

Applicants role in protocol(Required)

Billing Information

Speedchart #(Required)

(this information is provided by the research leader)

Project specific risk assessment comments(Required)

Instructions

All components of this form must be completed prior to submission.

This form will be sent to the IACUC Coordinator/Animal Care Manager. Your participation information will be recorded and the form will be forwarded to Campus Health Services (CHS).

You will be contacted by CHS to fill out an online health history form. The form can also be accessed at nau.edu/campushealth. Non-NAU-affiliated personnel will work with CHS to complete the health history form.

Generalized information with respect to allergies, chemical sensitivities, hearing loss, vaccination status and physical ability to perform a given task may be shared with BSA staff. You will be asked to sign a “release of medical information” form before this happens.

After completing your health history form, a member of the CHS team will review your information and determine if a medical health exam is required. Medical health exams are typically reserved for individuals with relevant health concerns, a high level of animal contact, or those needing specialized vaccinations.

A member of CHS will contact you to schedule a health examination if necessary.

Please note there is a “No Show” fee if you miss your medical health exam appointment and don’t call ahead of time to cancel it. The applicant is responsible for this charge, not their department.

CHS will alert the IACUC when all components of the occupational health enrollment process have been completed.

Species and anticipated level of contact

Use the accompanying descriptions to complete the checklists below.

Level 0: Individuals who are listed on IACUC approved protocols but who do not come into contact with live animals, their tissues or waste materials. To qualify for Level 0 status, an individual must not enter areas where animals are housed or where animal procedures are taking place. You must not directly observe others working with animals, their tissues or waste products.

Level I: Individuals who have minimal contact with live animals, their tissues and/or waste products. Level I status is typically reserved for individuals who do not provide daily care for live animals, do not routinely process or handle animal tissues. These individuals are occasionally present around animals, their tissues or waste products but not work directly with them on a routine basis.

Level II: Individuals who have routine contact with animals, their tissues or waste products. This person performs simple procedures which require handling and restraint of animals. This may include but is not limited to; animal transfers, cage cleaning, room sanitization, feeding, injections, oral gavage and euthanasia.

Level III: Individuals who have routine contact with animals, their tissues and/or waste products. In addition to minor procedures listed in the Level II description, this person performs advanced procedures with prolonged exposure to animals and with a higher risk of contact with animal pathogens, allergens etc. This may include but is not limited to; surgery, anesthesia, necropsy, tissue harvesting, processing and disposal.

If you have a history of allergies, asthma, breathing difficulties, bronchitis, or an immune compromising condition, you are strongly encouraged to participate in the NAU IACUC Occupational Health Program at least at the Category 3 level, regardless of your true level of animal contact.

Level of contact

Lab raised mice/rats

Level 0

Level I

Level II

Level III

List individual species

Rabbits

Level 0

Level I

Level II

Level III

List individual species

Birds

Level 0

Level I

Level II

Level III

List individual species

Reptiles

Level 0

Level I

Level II

Level III

List individual species

Amphibians

Level 0

Level I

Level II

Level III

List individual species

Fish

Level 0

Level I

Level II

Level III

List individual species

Wild rodents

Level 0

Level I

Level II

Level III

List individual species

Bats

Level 0

Level I

Level II

Level III

List individual species

Wild mammals/carnivores

Level 0

Level I

Level II

Level III

List individual species

Farm animals

Level 0

Level I

Level II

Level III

List individual species

Other

Level 0

Level I

Level II

Level III

List individual species

Approximate number of hours per week of animal contact(Required)

Participation/declination(Required)

I have reviewed the Occupational Health Enrollment form.

I understand that my animal contact may be considered a health risk and that I am invited to participate in the NAU IACUC Occupational Health Program.

I understand that declining to participate in the NAU IACUC Occupational Health Program may limit my ability to work with some animal species (skunks, foxes, bats, wild carnivores, etc.).oice

I understand that immunization against certain diseases (rabies, tetanus, hepatitis, etc.) may be required depending on the species I am working with and level of animal contact.

In Recognition of the above(Required)

I ACCEPT participation on the NAU IACUC Occupational Health Program.

I DECLINE (level 1 and 2 level of animal contact only) to participate in the NAU IACUC Occupational Health Program.

If this application is an annual re-enrollment

I certify that there have been no significant changes in my health status, the animal species I am working with or my level of animal contact. I decline having a medical health exam.

There have been significant changes in my health status, the animal species I am working with or my level of animal contact. I request to have my application considered by Campus Health Services which may require a medical health exam.