All personnel are required to complete this questionnaire. This Risk Assessment Questionnaire is designed to provide FAU with the information about occupational exposure and risks associated with the position identified in Section 3. All employees enrolled in the program will require in-person evaluation by FAU Student Health Services.

This Questionnaire must be completed between the employee/student and the PI/supervisor.

After Sections 1, 2, and 3 are completed, the INDIVIDUAL and SUPERVISOR MUST SIGN THE QUESTIONNAIRE.

Submission Instructions: This form MUST be submitted to Student Health Services (SHS). Please go to www.fau.edu/shs/occ-health-intake to upload this form and complete additional forms required by SHS. Within 2 business days of submission, you will be contacted by SHS to schedule an appointment. For questions about this process, you may contact the FAU Biosafety Officer (BSO@fau.edu).

All personal health and medical information collected by FAU is confidential.

Section 1: Type of Medical Service Requested
☐ Scientific Diver (Requires completed supplemental Diving Examination Forms)
☐ Research Animal Contact (Direct/Indirect) (Requires completed supplemental submission of Animal Contact Form in BioRAFT)
☐ Hazardous Materials Worker (EHS Personnel Only)
☐ Hearing Conservation
☐ Respiratory Protection (Requires completed supplemental Respiratory Protection Questionnaire)
☐ Bloodborne Pathogens
☐ Other (Specify):

Section 2: Personal Information
Name:	☐ Male	☐ Female	Date of Birth:	Today’s Date:
Department:	Position Title:	Campus: ☐ Boca ☐ Jupiter ☐ Davie ☐ HBOI ☐ Ft. Lauderdale ☐ Dania Beach ☐ Other Specify:
Home Phone:	Email address:	Supervisor:
Position Description: (check all that apply)
☐ Principal Investigator	☐ Researcher	☐ Veterinary
☐ Animal Care Tech	☐ EH&S	☐ Student
☐ Staff	☐ Post-doc	☐ Faculty
☐ Facilities Staff	☐ PD	☐ Other Specify:
Brief Job Description. Include all hazardous work that may be subject to medical surveillance:

Section 3. Occupational Exposure to Hazards
Are you or will you be working with any agent from the following hazardous groups? (Check all that apply)
☐ Recombinant/synthetic nucleic acids (DNA/RNA)	☐ Infectious agents	☐ Human or nonhuman primate cells/tissues/fluids
☐ Biological Toxins or Venoms	☐ Viral Vectors	☐ Formaldehyde
☐ Carcinogens	☐ Acutely Toxic Chemicals	☐ Reproductive Toxins
☐ Radioactive Materials	☐ Lasers	☐ Nanomaterials
☐ Hazardous Materials	☐ Asbestos
Please list all substances that fall into the above categories:
Will you be required to use a respirator for any part of your job? If yes, please review the FAU Respiratory Protection Program here: https://www.fau.edu/ehs/policies-and-procedures/ehs04-respiratory-protection.pdf.	☐ Yes	☐ No
Will your work involve scientific diving? If yes, please review the FAU Scientific Diving Safety Program here: https://www.fau.edu/ehs/info/scientificdiver/	☐ Yes	☐ No
Will your work involve exposure to loud noises?	☐ Yes	☐ No
Will your work involve contact (direct or indirect) with animals? If yes, you are required to enroll in the Animal Research Medical Monitoring Program (https://www.fau.edu/ehs/safety/medicalmonitoringprogram/). Please identify the animal species below: Rodents: ☐ Mice ☐ Rat ☐ Other: Others: ☐ Marine mammals ☐ Birds ☐ Dogs ☐ Fish ☐ Reptiles/Amphibians ☐ Pigs ☐ Cats ☐ Octopuses ☐ Non-human primates ☐ Other (list):	☒ Yes	☐ No
Will you require access to restricted areas such as laboratories that use biological hazards, animals or radiation? If yes, please specify:	☐ Yes	☐ No
Will your work potentially involve contact with hazardous materials, including asbestos? If yes, please specify:	☐ Yes	☐ No

Signature from the employee and supervisor or PI is required to ensure this form accurately describes the applicant’s job and workplace environment. This form must have both signatures before scheduling an appointment with SHS.

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Employee/Applicant Name	Employee/Applicant Signature	Date

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Supervisor/Manager/PI Name	Supervisor/Manager/PI Signature	Date