UCSD IACUC Protocol #: List location(s) [Country/Region]:

Created 01/08 || Revised 05/2020

AUCSD Environment, Health, and Safety

Risk Assessment Work Evaluation Questionnaire for Research Participants with Animal Exposure

Purpose: This form is provided to Principal Investigators (P.I.) for the purpose of identifying specific work exposures and potential health hazards in the work environment. Form A is used in conjunction with the Medical History Questionnaire (Form B) for participants with research animal contact to determine what health and safety services or recommendations are appropriate for the individual to work safely with research animals. Instructions: The P.I. must complete form A for each individual under their supervision with research animal contact. Both the P.I. and research participant must sign the completed form A. Both of the completed forms A and B should be sent to theEH&S/Occupational Health. Please bring the forms in person to CRSF room 231, fax to 858-724-3054, or mail to code 0090.For questions, contact EH&S/Occupational Health Nurse at 858-534-8225. COEM review process takes 7 to 10 working days.

SECTION A: Research Participant Information

Participant Name:

Email Address: UCID#: Participant Home Institution: UCSD Other (specify):

Company/Home Institution: **Submit a completed Form A and attach your home institution medical clearance for research animal contact. If medical clearance documentation is not attached, you must also complete Form B (medical history questionnaire).

Research Participant Status (check all that apply):

UCSD Faculty UCSD Staff UCSD Registered Volunteer UCSD-Paid Undergraduate Student UCSD-Paid Graduate Student/Post Doc Visiting Scientist*

UCSD Non-Paid Undergraduate Student*UCSD Non-Paid Graduate Student/Post-Doc*Affiliate** (Non-UCSD participants, e.g. Biotech/BioPharm Industry)

SECTION B: Principal Investigator (P.I.) InformationIACUC Protocol #:

Phone: Department:

SECTION C: Must be Completed by Principal Investigator

•Is animal husbandry an essential part of the participants duties?

Will the participant’s animal work involve potential contact with:•Human blood, tissues or cells administered to or present in animals?

Please list (specific type):•Infectious agents in animals? (Including but not limited to viral vectors, virus, bacteria, fungi, protozoa, parasites or prions)

Please list (names of specific agents):•Biological toxins in animals? (Including but not limited to Tetrodotoxin, Pertussis, Cholera, Diphtheria, Cardiotoxin)

•Pregnant mammals (EXCLUDING RODENTS)•Wild-caught mammals or wild-caught birds•Venomous animals (Including, insects, fish, etc.)

Please list (names of specific toxins):

Complete this form, along with Form B (Medical History Questionnaire)Please bring both A&B forms to EH&S/Occupational Health office at CRSF room 231, fax to 858-724-3054, or mail to code 0090. To protect your privacy, please put all forms in a sealed envelope.

Principal Investigator Name: Email Address:

Last Name First Name

BUA #:

•Will the participant be involved in any animal work off-campus (e.g.field work - local or abroad)? If yes, please providea description of which animals and what field work entails (e.g. administer anesthesia, collecting samples, or etc...):

Yes No

•Fresh or frozen tissues or fluids from non-human primates

Chemicals, including anesthetic gases, in animals. If yes, please list:•

Page 1 of 2

*covered by EH&S

Job Title:

Cell/Home Phone:

Index # (Obtained from your P.I.:

Page 2 of 2 Created 01/08 || Revised 05/2020

ASECTION C: continued Species Contact: Identify all levels of exposure for each species or animal tissues or fluids for the research participant and check the appropriate column(s). Check “0” if no direct or indirect contact. Check Non-Human primate (NHP) if handling NHP tissues or fluids or if participant works in an area where NHP or NHP tissues or fluids are housed or handled.

Level 0 - No animal contact.Level 1 - No direct contact, but enters area where research animals are used.Level 2 - Does not conduct procedures on live animals but handles fresh or frozen animal tissues or fluids.Level 3 - Handles, restrains, collection of specimens or administers substances to live animals.Level 4 - Performs invasive procedures such as surgery, necropsy.

LEVEL OF EXPOSURE LEVEL OF EXPOSURE

Species 0 1 2 3 4 Species 0 1 2 3 4

Amphibian Marine Mammal

Birds Mice

Cat Horse

Cattle Poultry

Dog Non-Human Primate

Ferret Rabbit

Fish Rat

Gerbil Reptile

Goat Sheep

Guinea Pig Swine

Hamster WILD- Rabbit/Mice/Rat

Other List:

SECTION D: Principal Investigator Certification

By signature, I certify that the information provided is accurate to the best of my knowledge.

AM/PM

PRINCIPAL INVESTIGATOR SIGNATURE DATE TIME

By signature, I acknowledge and agree with all of the above.

AM/PM

RESEARCH PARTICIPANT SIGNATURE DATE TIME

Complete this form, along with Form B (Medical History Questionnaire)Please bring both A&B forms to EH&S/Occupational Health office at CRSF room 231, fax to 858-724-3054, or mail code to 0090. To protect your privacy, please put all forms in a sealed envelope.