BIOSAFETY RISK ASSESSMENT FORM

BIOSAFETY RISK ASSESSMENT FORM

The Occupational and Diving Medicine Centre / NUS OH Clinic

This questionnaire will only be used for purpose of assessing fitness to work with biological agents. The questionnaire meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for medical information. A password protected copy of filled questionnaire will be emailed to you to print and bring down to clinic.
Name (according to NRIC/FIN/ID)*
Job Designation
NRIC/FIN (last 4 characters)
Staff / Student Number (NUS only)
Department, Institution
Email*
example@example.com
Type of Evaluation

Pre-employmentPre-placementPeriodicExitRequested
What Biosafety Level Lab will you be working in?

BSL2BSL3
List the Biological Agents that you will be working with
What research activites will you be handling in the lab?

Cell cultureCell culture of virus infected cellsProcessing of human tissuesProcessing of animal tissuesHandling Hepatitis B or C viruses and liver toxic materials like AflatoxinsFor BSL3 lab - it is a mixed pathogen lab
What other lab hazards are you exposed to?

lonising RadiationLasersHazardous chemicals (eg corrosives, carcinogens, toxics)Lab Animals or its tissuesHuman specimens eg blood, tissues, other body fluids

Do you have the following medical conditions?

	No	Yes	Elaborate	Dr Comments
Work related injury/disease
Tuberculosis or close contact with TB patient
Diabetes mellitus
Autoimmune disease eg SLE, Rheumatoid arthritis
Cancer
Chronic viral infection (eg Hepatitis B, C, HIV)
Congenital conditions resulting in immunodeficiency
Chronic steroid or immunosuppressive drug use
Chronic lung condition eg asthma, pneumothorax
Chronic disorder of blood cells
Environmental allergies
Latex allergies
Eye or visual problems
Heart disease
Frequent neck, arm, back pain
Giddiness or loss of balance
Fainting or fits/epilepsy
Paralysis, muscle weakness or numbness
Currently pregnant or planning in next 6 months
Musculoskeletal conditions
COVID Infection

Do you have the following health habits?

I smokeI drink alcohol regularlyI exercise regularly at least twice a week.I do not exercise regularly
What vaccinations have you taken? (Please key in the dates in the next section and attach any proof at end of questionnaire)

TetanusTdap (Tetanus+Diptheria+Pertussis)Hepatitis BInfluenzaHepatitis ACOVIDRabiesQ FeverMeningococcalMMR (Measles+Mumps+Rubella)ChickenpoxI do not have any of the mentioned vaccinationsOther vaccines. Please specify:
Details and Dates of vaccinations that you have taken
Date and Results of previous Hepatitis B screen (HBsAg) and titre value (IU/L)

Assessing Allergy and Asthma. Do you have the following?

	No	Yes
Allergy to animals
Any other allergies
Asthma
Hand dermatitis or eczema
Shortness of breath at work

Please elaborate any YES answers
Declaration

I declare that I have answered this form truthfully and to the best of my knowledge. I understand that my institution at its discretion can choose not to bear costs of any future illness or treatment should there be false or incomplete declaration of the above.I consent for the relevant information to be conveyed to my Supervisor or Department.I consent to the release of my medical details to the treating clinic/hospital/doctor(s) concerned in the event of an incident or where deemed
Student/Staff Signature (please sign appropriately)*

Clear
Date of Submission*

DayMonthYear
Date
File Upload

Cancelof
TO BE FILLED BY CLINIC ONLY
Height (m)
Weight (kg)
BMI
Blood Pressure (mmHg)
Pulse Rate (BPM)

Color Vision

NormalPartial deficiencyTotal deficiency
Hep B screen

NegativeImmune. Titres and date:

Physician Remarks
Date of Consultation

DayMonthYear
Date
CERTIFICATION OF FITNESS
Outcome of evaluation

Fit to work with no restrictionsFit to work with restrictionsTemporary unfit to workPermanently unfit to workFit for Exit BSL3 LabFit to work with wastewater samples
Presence of medical conditions that can place examinee at increased risk of performing work duties

YesNo
For protection of the health and safety of examinee, the following is recommended:

Hepatitis B screen/vaccinationCOVID vaccinationInfluenza vaccinationFull blood count, ESR, glucoseLiver/Renal functionChest XrayQuantiferon TB TestTuberculin Skin TestPneumococcal vaccinationJapanese Encephalitis vaccinationRabies screen/vaccinationLiver functionKidney functionHepatitis A screen/vaccinationPoliomylelitis vaccinationTyphoid vaccinationTetanus vaccinationTetanus, Pertussis, Diptheria vaccinationMeningococcal vaccinationMalaria ParasiteCan consider Jynneos Smallpox vaccine (if working with MPox)Other
Hepatitis B

Not immune. Advised vaccination.Not screened. Advised screening/vaccination.Immune.Titres:
Hepatitis A

Not immune. Advised vaccination.Not screened. Advised screening/vaccination.Immune.Titres:
Tetanus

Not immune. Advised vaccination.Not screened. Advised screening/vaccination.Immune.Titres:
Flu vaccine

Not valid. Advised vaccination.ValidDate
Physician Remarks
Mask Fitted for
BSL OH Number
Validity

1 year2 years3 yearsWhen there's change in health statusNot Applicable5 yearsOther
Dr Gregory Chan, Signature

Clear
Date

DayMonthYear
Date
Time

Hour Minutes

AM/PM Option
Should be Empty:

	Far - Uncorrected	Far - Corrected	Near - Uncorrected	Near - Corrected
Right Eye
Left Eye

	Normal	Abnormal	Notes on Abnormalities
Eyes
Ears, nose, throat
Cardiovascular
Respiratory
Neurological
GIT
Musculoskeletal
Skin
Psychiatric
Others

TO BE FILLED BY CLINIC ONLY

CERTIFICATION OF FITNESS