UCSD IACUC Protocol #: List location(s) [Country/Region]: Created 01/08 || Revised 05/2020 A UCSD 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 the EH&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: * a 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.) Information IACUC 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 provide a 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.: