• 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. 

  • Type of Evaluation
  • What Biosafety Level Lab will you be working in?
  • What research activites will you be handling in the lab?
  • What other lab hazards are you exposed to?
  • Do you have the following medical conditions?
    Rows
  • Do you have the following health habits?
  • What vaccinations have you taken? (Please key in the dates in the next section and attach any proof at end of questionnaire)
  • Assessing Allergy and Asthma. Do you have the following?
    Rows
  • Declaration
  • Date of Submission*
     / /
    2 digit day, 2 digit month, 4 digit year
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  • TO BE FILLED BY CLINIC ONLY

  • Visual Acuity
    Rows
  • Color Vision
  • Systemic Review
    Rows
  • Date of Consultation
     - -
    2 digit day, 2 digit month, 4 digit year

  • CERTIFICATION OF FITNESS

  • Outcome of evaluation
  • Presence of medical conditions that can place examinee at increased risk of performing work duties
  • For protection of the health and safety of examinee, the following is recommended:
  • Hepatitis B
  • Hepatitis A
  • Tetanus
  • Flu vaccine
  • Validity
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Time
  • Should be Empty: