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Employee Occupational Health Assessment- Initial PreplacementThe purpose of this evaluation is to screen for immunity to communicable diseases and to identify physical, mental, or emotional impairments thatcould affect your ability to perform the job that you have been offered. Whenever such impairment is present, we will assist you with the reasonableaccommodation process (see www.access.duke.edu). This evaluation is not a comprehensive health review to identify hidden disease or to offer medicaltreatment.The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of anindividual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provideany genetic information when responding to this request for medical information. “Genetic Information”, as defined by GINA, includes anindividual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s familymember sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or anembryo lawfully held by an individual or family member receiving assistive reproductive services.Name (Print)Duke Unique ID #:first name, middle initial, last nameAddress:Birth date:Cell/Home phone:City, State, zip code:Email:Title of the job you have been offered:Start Date:Dept/work area:Supervisor/ Manager:Work phone:Check entity where you will be employed:Duke University HospitalDuke RegionalRaleigh Ctr Labco Duke University - SOM, SON, DukePrimaryCare Private Diagnostic Clinic Patient Revenue Mgmt Org. HomeCare/Hospice Assoc. Health Svc/Davis Ambulatory Surg Duke Ctr DUHS - Company20, Corporate ServicesEmployment InformationWill you work with:Contact, orContact Patient No PatientLabBlood Body Fluid Exposureanimals Do you have any current disability or physical conditionrequiring restricted activity?YesNoHave the physical demands of the job been described to you?YesNoUncertainDo you have any lifting restrictions? Yes NoIf yes, state restrictions: Use separate sheet if neededPlease state your understanding of the amount of weight and frequencyof lifting required in this job:lbs. (ex. Up to 10, 25, 30, 50, 75, or over 75 lbs.)frequency (ex. Up to 1/3, 2/3, or whole shift) Do you have decreased ability to lift, carry, push/pull, andtransfer patients and/or equipment/ materials as described inyour employment interview and/or health assessment?YesNo If yes, are these restrictions:PermanentTemporary until Can you perform the essential functions of this job?YesNoUncertain If no, will you require a job modification to accommodatea disability? (Speak with EOHW or see http://access.duke.edu formore information about making a request for an accommodation.) Yes No UncertainOccupational History – List your last three positions, starting with the most recent.1JOB TITLE/ Length of employmentBRIEF JOB DESCRIPTIONDUTIES PERFORMED23List ALL current medications/treatments (including non-prescription), the condition treated, date begun.MedicationDosageConditionStart Date
Functional Self-Assessment(Check all that apply)1. Do you have any of the following?Y N Y N NLoss of vision in either eye that cannot becorrectedLoss of vision requiring correctionselect type of correction needed (if applicable):Near CorrectionEyeglasses Far CorrectionContact LensesY Any color vision deficiencies?YY N N Loss of hearing that is correctedLoss of hearing that is not corrected2. Do you have decreased function in any of the following?Y N Either arm/hand, including grip/reach, use offingersY N Neck or lower back (such as arthritis, orpinched nerve) N Hips, knees, ankles, or feetYIf yes to any of the above, provide comments:3. Do you have decreased ability in any of the following?Y N To stay awake or maintain consciousness(due to such causes as seizures, diabetes, or sleepdisorder)Y N To breathe or maintain endurance (due tosuch causes as asthma, emphysema, or angina)Y N To fight off infection (due to such causes asimmune deficiency, diabetes, HIV infection, drugs forrheumatoid arthritis, cancer, and other illnesses)Duke ID4. Do you have physical problems (such as seizure disorder, diabetes,allergies) or mental/emotional problems (such as anxiety, attentiondeficit disorder, or claustrophobia) that could interfere with any ofthe following?YYY N N N Y N Y N Y N Y N Y N Managing multiple tasks at one timeFocusing on job tasksWorking rotating shifts (nights, evenings)Working with soaps, detergentsWearing glovesUsing a respiratorWorking with radiation or chemotherapy agentsWorking with animalsIf yes to any of the above, provide comments:5. Have you ever experienced any of the following?YY NA substance abuse/dependence problem? AnNalcohol abuse/dependency problem? 6. Y N Were you told by a health care professional that you have alatex allergy? If yes, check the symptoms you had related to latex exposure: ItchingRunny or stuffy noseShortness of breath Sneezing Rash/skinWheezingirritation Anaphylaxis, intraoperative shock, or hives due to such causes ascatheter or condom use?7. Y N Have you experienced itching or swelling of the throat or lipswhile eating or during dental work?8. YNWere you born outside of the US? N Have9. Yyou had the BCG vaccine? N Have you10. Yhad the polio vaccine? Do you have11. YNquestions regarding general health, reproductive health, or other safety issues at work?If yes to any of the above, provide comments:I authorize EOHW or its representative to access my record in the North Carolina Immunization Registry.I certify that the information I have provided is true to the best of my knowledge. I understand and agree to authorize Duke Employee OccupationalHealth & Wellness to review any information (including, but not limited to, information relating to psychiatric/psychological and alcohol andsubstance abuse diagnosis and treatment, if any such information exists) at Duke or other health care providers for purposes related to my fitness foremployment. I agree to any reasonable subsequent testing or evaluation deemed necessary to determine my fitness to perform this job, and Iauthorize the examining provider to forward pertinent information to those who would perform such testing or evaluation. I understand that Duke isrelying upon my representations contained herein and they are substantial employment factors. I further understand that misrepresenting the factsmay result in forfeiture of this employment opportunity. I understand that this information will become part of my confidential EmployeeOccupational Health record and is not shared with management.Applicant’s SignatureDate mm/dd/yyReviewer’s SignatureDate mm/dd/yy \Common\Remote Clearance Forms\Current Individual Forms \Common\EOHW FORMS\form-placement health review\Placement Health Reviews-Initial
1Duke University Employee Occupational Health & WellnessHEALTH REVIEW FOR ANIMAL HANDLERSNameBirth Date Duke Unique ID#Cell/Pager (opt): Work Phone: Email Address:Duke Job Title: Dept./Address/Work Area:Duke Box #: Duke Supervisor Name & Phone:Employees in certain job categories are required to undergo a health review at the beginning of their job and at periodicintervals. This policy includes Duke personnel who work with animals and in animal facilities. Please complete this formand submit it. The EOHW nursing staff will review it and notify you if you need to come in for further review. Please callEmployee Occupational Health at 684-3136 option #2 if you have any questions and a member of the EOH staff will assistyou. Documentation of measles immunity and a current TB test are required for work with and in facilities housing nonhuman primates.The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiringgenetic information of an individual or family member of the individual, except as specifically allowed by this law. Tocomply with this law, we are asking that you not provide any genetic information when responding to this request formedical information. “Genetic information” as defined by GINA, includes an individual’s family medical history, theresults of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family membersought or received genetic services, and genetic information of a fetus carried by an individual or an individual’sfamily member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.EOHWBox 3148 Med Ctr Fax 919-681-0555ALL INFORMATION IS STRICTLY CONFIDENTIALI certify that the information below is true, complete, and correct to the best of my knowledge and belief. I understandthat intentional misstatements or omissions may be grounds for disciplinary action which could include termination.SignatureDate – mm/dd/yyY[ ] N[ ] I will be working with animals, cages, or bedding.[If yes, answer Section 2, questions #1 through #19]Y[ ] N[ ] I will be working in facilities where animals are housed but I will not handle animals, cages, or bedding. Thisincludes those doing walk through inspections, those providing housekeeping, and those providing maintenance andrepairs. Documentation of measles immunity and an annual TB review are required for employees working in facilitieshousing nonhuman primates.[If yes, answer Section 3, questions #20 through #24.]
2Section 2.Working with animals, their cages, or bedding1. Y[ ] N[ ] I have previously completed this health review. [If yes, complete question #2. If no,Skip to question 3.]2. Have you developed any of the following conditions since your last health review?a. Hay feverY[ ] N[ ]b. AsthmaY[ ] N[ ]c. Allergic skin problemsY[ ] N[ ]d. Immune system suppressionY[ ] N[ ]If yes to any of the above, please describe:e. List any other new health issues since your last health review :[then skip to question #4]3. Do you now have or have you ever had any of the following:Y [ ] N[ ] a. Diabetes?Y [ ] N[ ] b. Seizure disorder?Y[ ] N[ ] c. Skin rashes?Y [ ] N[ ] d. Glove allergies/rashes?Y[ ] N[ ] e. Diagnosis of latex allergy?Y[ ] N[ ] f. Asthma?Y[ ] N[ ] g. Hernia or herniated disc?Y[ ] N[ ] h. Allergies to pollen, food, animals, etc.?Y[ ] N[ ] i. Muscle or bone problems?Y[ ] N[ ] j. Repeated episodes of diarrhea?Y[ ] N[ ] k. Drug or alcohol dependency?Y[ ] N[ ] l. Have you ever had measles?Y[ ] N[ ] m .Measles vaccine?Y[ ] N[ ] n. Problems with visual acuity/hearing ability?Y[ ] N[ ] o. Rabies vaccine series? Year (optional)Y[ ] N[ ] p. Immune system suppression?If yes to any of the above questions, please explain:4. Y[ ] N[ ] Unknown [ ] Was your last tetanus vaccine within the last 10 years? If longer than 10 years a booster ishighly recommended and can be obtained from EOHW or your personal health care provider.5. a. Y[ ] N[ ] I work in a setting where animals are used. The species which may be in my work area include:b. Y[ ] N[ ] I am a DLAR employee and may work with or enter the areas where all species are maintained by DLARincluding rodents, rabbits, dogs, cats, nonhuman primates, ferrets, birds, sheep, goats, fish, and other species: anannual TB test and proof of measles immunity are required.[If yes, skip to question #6. If no, go to #5c.]c. Y[ ] N[ ] Will you be working with nonhuman primates? (DLAR employees should check yes.)[If yes, complete #6. If no, skip to question #7.]
36. a. Y[ ] N[ ] Have you had a TB skin test? (EOHW must have documentation of a recent test or questionnaire,required for baseline and annually)b. Y[ ] N[ ] Does EOHW have documentation of your measles immunity? If no, documentation of immunity isrequired which consist of a positive blood test for measles antibody or 2 doses of measles vaccine.If unsure about these requirements you may call EOHW at 684-3136 option #2.7. Y[ ] N[ ] Do you have any safety/health concerns about chemicals you are working with? If yes, pleasedescribe.8.Y[ ] N[ ] Have you ever been fit tested for a respirator to wear while working with lab animals?9. When working with animals, how often do you wear the following?a. Gloves[ ] never[ ] sometimes [ ] alwaysb. Gown[ ] never[ ] sometimes [ ] alwaysc. Surgical Mask[ ] never[ ] sometimes [ ] alwaysd. Disposable Respirator[ ] never[ ] sometimes [ ] alwayse. Non-disposable Respirator [ ] never[ ] sometimes [ ] alwaysf. Goggles[ ] never[ ] sometimes [ ] alwaysg. Face shield[ ] never[ ] sometimes [ ] always10. How frequently do you wash your hands after handling animals/animal products?[ ] never [ ] sometimes [ ] always11. Y[ ] N[ ] Have you been evaluated for animal related health problems? If yes, please list:12. Y[ ] N[ ] Do you have any work restrictions/limitations? If yes, please explain:13. Y[ ] N[ ] Do you have sneezing spells, runny or stuffy nose, watery or itchy eyes, coughing, wheezing, or shortness ofbreath after working with laboratory animals or their cages/bedding? [If no, skip to question 14.]If yes, please answer the following:a. When did the symptoms begin? (month & year)b. Y[ ] N[ ] Are the symptoms worse than one year ago?c. Y[ ] N[ ] Are you taking medications to control symptoms? If yes, please list:d.Check all of the following that cause any of your symptoms.Guinea tAquatics/fishAmphibiansReptilesUnsure: Other:
414. In general, how frequently are you bothered by the following symptoms related to work/exposure toanimals ortheir cages or bedding?a. Skin rash or hivesNot troubled [ ]Monthly [ ]Weekly [ ]Daily [ ]b. Watery, itchy eyes Not troubled [ ]Monthly [ ]Weekly [ ]Daily [ ]c. Runny or stuffy nose Not troubled [ ]Monthly [ ]Weekly [ ]Daily [ ]d. Sneezing spellsNot troubled [ ]Monthly [ ]Weekly [ ]Daily [ ]e. Frequent coughNot troubled [ ]Monthly [ ]Weekly [ ]Daily [ ]f. Wheezing in chestNot troubled [ ]Monthly [ ]Weekly [ ]Daily [ ]g. Shortness of breath Not troubled [ ]Monthly [ ]Weekly [ ]Daily [ ]15. Y[ ] N[ ] Do you have any house pets?If yes, what type(s) of animals?16. Y[ ] N[ ] Have you had any on-the-job injuries or exposures you have not reported?If yes, please describe.17. How frequently do you work with sheep, cows or goats? (DLAR employees who work with these animals shouldcheck daily.)[ ] daily[ ] once a week[ ] once a month18. Y[ ] N[ ] Do you directly handle birth products of sheep, cows, or goats? (DLAR employees who work withanimals should check yes to indicate the potential to work with sheep, cows, and goats.)If yes, which animals?19. Y[ ] N[ ] Would you like to speak with an EOHW provider about an animal related health issue?Reviewed by Date
5Section 3Working in animal facilities where animals are housed but not handling animals, cages, or, bedding.20. Health HistoryY[ ] N[ ] Allergies to pollen, food, animals, etc.?Y[ ] N[ ] AsthmaY[ ] N[ ] Immune system suppression?If yes to any of the above questions please explain:21. Y[ ] N[ ] Do you have sneezing spells, runny or stuffy nose, watery or itchy eyes, coughing, wheezing, or shortness ofbreath after working in animal facilities? [If no, go to question #22.]If yes, please answer the following:a. When did the symptoms begin? (month & year)b. Y[ ] N[ ] NA [ ] Are the symptoms worse than one year ago?c. Y[ ] N[ ] Are you taking medications to control symptoms? If yes, please list:d.Check all of the following that cause any of your symptoms.Guinea tAquatics/fishReptilesAmphibiansOther:Unsure:e. In general, how frequently are you bothered by the following symptoms related to time working in animalfacilities?a.b.c.d.e.f.g.Skin rash or hivesWatery, itchy eyesRunny or stuffy noseSneezing spellsFrequent coughWheezing in chestShortness of breathNot troubled [ ]Not troubled [ ]Not troubled [ ]Not troubled [ ]Not troubled [ ]Not troubled [ ]Not troubled [ ]Monthly [ ]Monthly [ ]Monthly [ ]Monthly [ ]Monthly [ ]Monthly [ ]Monthly [ ]Weekly [ ]Weekly [ ]Weekly [ ]Weekly [ ]Weekly [ ]Weekly [ ]Weekly [ ]Daily [ ]Daily [ ]Daily [ ]Daily [ ]Daily [ ]Daily [ ]Daily [ ]22. If you have completedthis questionnaire before, have you developed any of the following conditions since your lasthealth review?a. Hay feverY[ ] N[ ] NA[ ]b .AsthmaY[ ] N[ ] NA[ ]c. Allergic skin problemsY[ ] N[ ] NA[ ]d. Any new health issuesY[ ] N[ ] NA[ ]If yes to any of the above questions, please explain:
623. Y[ ] N[ ] Will you work in facilities housing nonhuman primates (monkeys)? [If no, go to #24. If yes, complete a & b.]a. Y[ ] N[ ] Does EOHW have documentation of your measles immunity? If no, documentation of immunity isrequired which consists of a positive blood test for measles or 2 doses of measles vaccine.b. Y[ ] N[ ] TB skin test. Documentation of a recent test or questionnaire is required. This can be done at theEOHW clinic in the Duke Clinic Building—phone 684-3136 option #2.24. Y[ ] N[ ] Would you like to speak with an EOHW provider about an animal related health issue?Reviewed by Date
Duke University Hospital Duke Regional Duke Raleigh University - SOM, SON, DCRI Ctr for Living - Health & Wellness Labco - DUHS Clinical Labs Duke Primary Care Private Diagnostic Clinic Duke HomeCare/Hospice Patient Revenue Mgmt Org. Assoc. Health Svc/Davis Ambulatory Surg Ctr DUHS - Company20, Corporate Services
