Transcription of HAZDRUGMedical Surveillance Questionnaire#5
1 chemotherapeutic Drug Handlers Health Surveillance History NameDirections: Please answer the questions on this form. (All information provided in this health history is kept strictly confidential and is used for only the purpose of health Surveillance of health care workers who handle hazardous drugs.) If you have any questions, concerns or problems completing this questionnaire, please contact Employee Health Services at 404-686-7947. Today s Date Address & Phone # Hire Date DOBSex Male Female Department & Job Title 1 How often do you handle hazardous drugs? Daily Semiweekly Weekly Monthly Other_____ 2 What types of hazardous drugs do you handle? 3 Do you wear Personal Protective Equipment (PPE) when handling hazardous drugs?
2 (Check all that apply) Never Rarely Sometimes AlwaysGloves Chemotherapy GownMaskCapGoggles/Glasses Shoe covers 4 Do you have any physical conditions or restriction that would affect your ability to wear PPE? No Yes, please explain: 5 Have you been exposed within the last two years to any leaks or spills of hazardous drugs? Did you report this exposure? No Yes, please explain. No Yes 6 Do you have a latex allergy? No Yes 7 Do you have any drug allergies? No Yes, please list 8 Do you have any chronic diseases or health conditions? No Yes, please list 9 Have you had any problems with the following: No Yes Explain Dermatitis Numbness Weakness Malaise Eye or Vision Problems Kidney Problems Anemia Blood Disorders/Abnormal Lab Tests Liver Disease/Abnormal Lab Tests Respiratory Problems/Asthma Chest Pain 10 Are you currently pregnant and/or breast feeding?
3 No Yes Not applicable 11 Have you had any reproductive problems? No Yes, explain 12 Do you know how to access MSDS information? No Yes Do you know how to access policies for chemotherapeutic Drugs? No Yes 13 Pharmacy Staff: Have you prepared or compounded high risk cytotoxics in a barrier isolator over the last year? No Yes I certify that the information provided by me in this questionnaire is complete and true to the best of my knowledge. Employee Signature Date Nurse Review Date 5/29/09
