Caltech Safety Forms and Documentation

EHS Forms and Documentation

LAB ANIMAL OCCUPATIONAL HEALTH (LAOHP) RISK ASSESSMENT FORM

Complete the Risk Assessment below.
Print a copy of the completed risk assessment.
Press "send" to submit the completed risk assessment.
Complete the medical questionnaire if you will be handling animals.

OCCUPATIONAL ENVIRONMENTAL RISK FACTORS
I. LABORATORY ANIMAL USE
*A. Select which statement is applicable to your status*:
	1. I am not handling animals but will be working in areas where animals are housed.
	2. I will be working with animals.
	3. I am involved in veterinary care or animal husbandry.
	4. I am working with human specimens (cells, body fluids, etc.) in conjunction with animal studies.

*B. Animal/ Tissues/ Body Fluids Used or Handled* (check all that apply)
		Frequency of Contact
		Daily	1-3 times/week	1-3 times/month	Infrequent (1-6 times/year)
	Rodents or rabbits
	Frogs, turtles, or fish
	Birds
	Non-human primates
	Other (specify)

II. RISK ASSESSMENT FOR LABORATORY ANIMAL USE
Provide the following for each agent you are exposed to in conjunction with animal studies (ie. studies involving the use of whole animals or animal tissues):
		Yes	No	If yes, specify agent
1.	Infectious Agents
2.	Chemical Carcinogens (eg. halothane, isofluorane, urethane, formalin)
3.	Recombinant DNA Technologies (Viral Vectors)
4.	Radiation
5.	Anti-Neoplastic Agents (eg. Cyclophoshamide)
6.	Known Reproductive Hazards/Teratogens
7.	Other

Note: Please refer to the Office of Laboratory Animal Resources' website at www.its.caltech.edu/~olar/ for complete information regarding zoonotic diseases (infections of animals which may be communicable to humans) when working with animals or in areas where animals are maintained.

The following information needs to be completed. Fields marqued with an * are required.

PERSONAL INFORMATION
Today's Date
Name*	(Last, First, M.I.)
Job Title
E-mail*
Work Phone*
PI/Supervisor
Department
Mail Code

I have answered the questions on this form truthfully and to the best of my recollection.


Signature (Print Name)	Date

Caltech Environment, Health and Safety (EHS) Office, Mail Code 25-6, Pasadena, CA 91125 Tel: 626 395 6727