Auhsp Medical Evaluation Form - Cornell University
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Animal Users Health and Safety Program (AUHSP)
AUHSP Medical Evaluation Form
INSTRUCTIONS: Please complete all applicable sections, sign the form, and return to:
Occupational Medicine Office, Gannett Health Services, 110 Ho Plaza, Ithaca, NY 14853-3101
Contact Gannett’s Occupational Medicine Department at 607-255-6960 for assistance.
Name (Last, First, M.I.)
Cornell ID Number
Preferred contact phone number (include area code)
E-mail address
Facility where research/animal exposure occurs
PI or Supervisor
A. TETANUS IMMUNIZATION
What is the year of your last tetanus immunization?
(CDC and New York State Dept of Health recommend tetanus immunization every 10 years.)
B. ALLERGIES/ASTHMA/SKIN PROBLEMS
1. Are you allergic to any animal(s)?
No
Yes
Don’t know
If yes, please list the animal(s) and their associated allergy symptoms
Have you had these animal allergy symptoms within the past 12 months?
No
Yes
If yes, what is the current severity of your animal allergy symptoms?
Mild
Moderate
Severe
What animal allergy treatment are you currently using?
2. Are you allergic to any environmental allergens such as grass, trees, pollen, dust?
No
Yes
Don’t know
If yes, please list environmental allergens and their associated allergy symptoms
Have you had these environmental allergy symptoms within the past 12 months?
No
Yes
If yes, what is the current severity of your environmental allergy symptoms?
Mild
Moderate
Severe
What environmental allergy treatment are you currently using?
3. Do you have asthma?
No
Yes
Don’t know
If yes, please describe your asthma triggers (if known)
Have you had asthma symptoms within the past 12 months?
No
Yes
If yes, what is the current severity of your asthma symptoms?
Mild
Moderate
Severe
What asthma treatment are you currently using?
4. Do you have allergy or asthma symptoms specifically related to your work?
No
Yes
Don’t know
If yes, please describe your allergy or asthma symptoms at work
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