MIDWESTERN UNIVERSITY (MWU)

Animal Facility Medical Monitoring Program – VISITOR FORM

Acknowledgement, Acceptance/Declination Statement

(This form should be used when any non-MWU employee or non-MWU student wishes to enter the animal facility, including but not limited to visitors, outside contractors, and inspectors)

Completion of this form is required for all non-MWU employees or non-MWU students who enter the animal facility. Failure to complete the form may result in the loss of privilege to enter the Animal Facility. Complete part 1 and part 2.

Part 1: Acknowledgement and Acceptance/Declination

1. I have received and understand the “Occupational Health Program for Animal Users” (see pages that follow). This form and program can be obtained from the Office of Research and Sponsored Programs or Human Resources Department.

2. I understand that a Tetanus immunization is normally recommended for all persons having animal contact, but since I

am not anticipated to come into contact with animals during this limited visit, a Tetanus immunization is not recommended.

3. I understand that my limited entry into an Animal Facility could pose a health risk, and I should pay attention to any changes in my health status, especially allergies.

4. In full recognition of the above:

I agree to abide by the Midwestern University “Occupational Health Program for Animal Users”, to the

extent that it applies to me.

5. Allergy status:

I have no known allergies to animals. I understand that it is recommended that I pay attention to my allergy status, particularly if I repeatedly enter animal facilities at multiple institutions. OR

I have allergies to animals and I’m enrolled in a Respiratory Protection Program at ______. I have been fit tested for my own personal protective equipment (i.e. a mask) and will bring it to wear while in MWU’s Animal Facility to minimize risks associated with allergies. OR

I have allergies to animals and I’m not enrolled in a Respiratory Protection Program elsewhere.

·  Visitors who fall into this category will be made aware of the “Basic Facts about Exposure to Research Animals at MWU”, but due to the one-time or limited exposure to animals, will not have a comprehensive risk analysis performed at Advocate Occupational Health.

·  Wearing a mask to minimize exposure to animals while in MWU’s Animal Facility will be recommended, and disposable N-95 masks in various sizes will be available on a voluntary basis (no medical assessment or fit testing will be performed).

·  By signing below, I acknowledge my understanding that wearing a N-95 mask may not fully protect me from an allergic reaction.

·  Visitors who understand and accept the risks, but voluntarily decide not to wear a mask, will be asked to sign a “Visitor - Waiver, Release, and Assumption of Risk Form”.

Part 2: Information (Please Print in the Table)

Name of Visitor / Date
Name of Employee who will accompany visitor into the Animal Facility / Phone of MWU Employee
Department of Employee who will accompany visitor / Email of MWU Employee

Signature of Visitor Signature of Employee who will accompany visitor

______

Signature of Respiratory Protection Program Administrator Revised 2/12


Occupational Health Program (OHP) for Animal Users

The health of individuals working in the Midwestern University Animal Facility is an area of concern to the University and its administration. As such, we have developed the following occupational health and safety program and procedures as a guide for all those who enter the Animal Facility. It has been designed using current federal guidelines (Institutional Animal Care and Use Committee Guidebook from The Office of Laboratory Animal Welfare (OLAW) of the NIH as well as the Guide for the Care and Use of Laboratory Animals published by the NRC) to minimize the risks associated with animal use. General oversight and operational responsibility for MWU’s OHP ultimately rests with the Institutional Official. In this role, the Institutional Official relies upon MWU’s Respiratory Protection Program Administrator, Human Resources, Risk Management and/or the health care professionals of Advocate Occupational Health.

I. Who will be involved?

All persons who enter the animal facility at Midwestern University will be required to fill out a Animal Facility Medical Monitoring Program Form (there are 3 different forms, one appropriate for MWU Employees, MWU Students or Visitors). The answers provided on that form, in conjunction with the anticipated extent of duties and/or anticipated number of times and duration the individual will enter the animal rooms, will determine the extent of enrollment in the OHP for Animal Users. Signage will be posted on the doors of the animal facility stating EVERYONE (faculty/staff/students/maintenance/security/visitors, etc.) who enters this Animal Facility MUST be risk assessed by the Animal Facility Medical Monitoring Program Form and receive the Occupational Health Program for Animal Users. If you have not completed this, or if you are not sure if you completed it, then please contact the Manager of Animal Resources. The Animal Facility Manager will help Human Resources in assuring that all people participate in this program prior to gaining ID access to the facility.

II.  Hazard identification and risk assessment

Step one is that all who enter MWU’s Animal Facility will have a preliminary risk assessment performed by filling out a Animal Facility Medical Monitoring Program Form. If deemed necessary by the Respiratory Protection Program Administrator, based on the history of animal allergies and the anticipated intensity, duration, and frequency of exposure to hazards posed by the animals and/or materials, the individual may be required to perform a more comprehensive risk assessment. Individuals with one-time or very limited access privileges to the animal facility may not be required to have a comprehensive risk assessment.

When necessary, the second step of a comprehensive Risk Assessment is performed by the health care professionals at Advocate Occupational Health. They have the collective expertise to perform a comprehensive health risk assessment, starting with a medical evaluation questionnaire. The questionnaire used is an OSHA mandated document which requires detailed information about your current/previous medical conditions. No MWU employee will see your responses to this questionnaire. Upon completing this information, the health care professional and/or the individual being risk assessed may request a meeting to address current health conditions, risks for conditions such as allergies and zoonotic diseases, any symptoms the individual may be experiencing, and any concerns either may have. You may be referred to specialists for additional testing.

A small number of employees, usually limited to the animal facility staff who frequently handles animals, bedding, and animal waste, will be required to perform annual physical exams and discuss any occupational health related issues with the health care providers at Advocate Occupational Health.

If Advocate Occupational Health professionals determine that the risks associated with a particular individual cannot be reduced to an acceptable level, the Respiratory Protection Program Administrator and the Institutional Official will be notified. The Institutional Official reserves the right to deny an individual the ability to enter the Animal Facility, if it is deemed in the best interest of the university and/or the individual.

III.  Potential hazards at Midwestern University

Allergy and musculoskeletal injury constitute the vast majority of health risks to individuals using and caring for laboratory animals. Infectious diseases also form a significant risk depending on the species and health status of animals involved and the level of exposure to them by animal care personnel, faculty, and technical staff. Animal bites and scratches are also common hazards. As a guide, the following table has been adopted from the OLAW Institutional Animal Care and Use Guidebook and should be used in constructing guidelines for those submitting animal use protocols.

OCCUPATIONAL HEALTH PROGRAM FOR ANIMAL USERS

Extent of animal contact:

Direct Contact with No Direct Contact

Species Used and Direct Regular Contact Limited Exposure (Occasional Exposure)

Other Risk Factors (³ 8 hrs/week) (£ 8 hrs/week)

Small animals

(Rabbits, rodents,

birds, etc.) 1, 2, 5 1, 2, 5

Dogs, cats, and

feral animals* 1, 2, 4 1, 2, 4

Primates* 1, 2, 3, 8 1, 2, 3, 8 3

Farm animals* 1, 2, 6 1, 2, 6

Amphibians, reptiles

fish, etc.* 2 2

Infectious disease

agents Biosafety Class

III or higher* 1, 2, 7, 8, 9 1, 2, 7, 8, 9 1, 2, 7, 8, 9

Work with animal

tissues 7 7 7

______

Code number Procedure

1 Pre-employment physical exam

2 Tetanus prophylaxis

3 TB test every 12 months

4 Rabies immunization

5 Pre-employment allergy history and education

6 Special education on large animals diseases

7 Special consideration by IACUC and Biosafety Committee subcommittees

8 Post-employment physical exam

9 Annual physical exam

*It should be noted that historically, the vast majority of animals used at Midwestern University have fallen under the heading of Small Animals (to include Rodents, Rabbits, Guinea pigs, etc.). We do not use dogs, cats, primates, farm animals or other large animals.

IV. Training of personnel

All employees and students who work with animals will receive “The Basic Facts about Exposure to Research Animals at Midwestern University”. Training involving animal protocols should be tailored according to each protocol and will best be conducted by the principal investigator of the study with the assistance and cooperation of the Animal Facility consultant veterinarian. (See also Midwestern University Institutional Animal Care and Use Program, Sec. IIA, par. 3c.)

All individuals will be provided with instruction by their supervisor regarding the nature of hazards they work with and particular precautions for avoidance or minimizing risks associated with the hazard. In some cases, this may require being enrolled in Midwestern University’s Respiratory Protection Program. In addition, personnel will be told and encouraged to report all injuries immediately to their supervisor and the Biosafety Committee Chair.

V. Personal hygiene

Personal hygienic practices should be tailored according to each protocol, especially with regard to personal and protective clothing (disposable gloves, masks, head covers, booties, coats, etc.; also see Personal Protective Equipment section below). A laundering service is available to all staff, faculty, and technical personnel. In addition, the Animal Facility has its own laundry available on an as needed basis. Hand washing after handling any animals will always be required. Eating, drinking, use of tobacco products, and cosmetic application will be strictly prohibited. (See also Midwestern University Institutional Animal Care and Use Program, Sec. IIA, par. 4c.)

VI. Personal Protective Equipment (PPE)

Animal care personnel should wear their MWU-issued protective clothing, shoes or shoe covers, and gloves whenever needed. When appropriate, personnel should shower when they leave the animal care or procedure areas of certain animals. Protective clothing and equipment should not be worn beyond the boundary of the hazardous-agent work area or the animal facility. Personnel with potential exposure to hazardous agent work areas will be provided with PPE appropriate to the agents. Hearing protection is provided and required in high-noise areas, such as when operating the bedding dispenser. Personnel working in areas where they might be exposed to contaminated airborne particulate material or vapors shall be enrolled in MWU’s Respiratory Protection Program where they will be provided with suitable respiratory protection, respirator fit testing, and training in the proper use and maintenance of the respirator.

VII. Facilities, procedures, and monitoring

See Midwestern University Institutional Animal Care and Use Program, Section IIB-C.

VIII. Animal experimentation involving hazardous materials

All protocols involving nuclear, biological, and chemical hazards must first be approved through the appropriate University safety committee. Policies for this are already in place (See the Midwestern University Research Safety Manual and Chemical Hygiene Plan and the Radiation Safety Handbook).