Office of Research Compliance

Institutional Animal Care and Use Committee

Institutional Animal Care and Use Committee

Animal Care Occupational Health Safety Program
Non-Employee Enrollment Form

The Boise State University Animal Care Occupational Health and Safety Program is a federal requirement to ensure the health and safety of individuals with animal exposure. To fulfill this goal, please complete the following risk assessment questionnaire pertaining to your animal related research/studies/work at Boise State University. Information collected in this questionnaire is confidential.

Name: / Date:
Anticipated duration of work with animals: / Date of Birth: / Job Title:
E-Mail: / College or Department:
Principal Investigator or Supervisor: / Work Phone: / Protocol #:
Role on the Protocol: ☐ P.I. ☐ Co-P.I. ☐ Lab Technician ☐ Research Assistant ☐Volunteer
☐ Other – specify:

What will be the extent of your exposure to animals at Boise State University?

☐ / No direct contact / ☐ / Less than 8 hours per week / ☐ / More than 8 hours per week

What species of animals will you be exposed to at Boise State University? (Check all that apply)

☐ / Lab mice or rats / ☐ / Lab zebrafish / ☐ / Lab birds
☐ / Arthropods (list): / ☐ / Lab or wild amphibians, reptiles, wild fish / ☐ / Wild birds (list):
☐ / Wild mammals (list): / ☐ / Lab rabbits

Principal Investigator/Supervisor Certification

By signature, I certify that the information is accurate, that I have provided or will provide prior to animal exposure the participant named above with the appropriate training and will communicate the associated risk for the animals they will be working with. The appropriate personal protective equipment will be provided to the participant at no charge.

Printed Supervisor Name:
Supervisor Signature: / Date:

Signature of Non-Boise State University Employee

I have been informed that due to my exposure to animals, I may be at risk of acquiring a zoonotic, allergic, or animal related disease. I should contact my primary care provider to discuss any concerns regarding animal exposure. I will notify the Boise State supervisor of all injuries, accidents, bites, scratches, and allergic reactions related to animal exposure work at Boise State University.

I understand that in the future, if I become a Boise State University employee, I can request to complete the Health History Questionnaire and discuss my animal exposure with an occupational health services provider.

Printed Participant Name:
Participant Signature: / Date:

05/10/2013