Form Approved
OMB # 0920-1011
expires 03/31/2017
Risk Assessment for Primate Research Center Employees and Inspectors
Investigation: Unidentified mode of transmission and risk factors for potential Burkholderia pseudomallei exposures among non-human primates, and persons employed at or inspecting a national primate research center — Louisiana, 2015
Risk Assessment for Primate Research Center Employees and Inspectors
What is your occupation (job title)? ______________________________________________________
Where you on the inspection tour on January 20-23? _____Yes _____No
Did you work with rhesus macaque IL38 or rhesus macaque1b22?
Husbandry? _____Yes _____No _____Maybe/Unsure*
Treatment of sick animal? _____Yes _____No _____Maybe/Unsure
Necropsy? _____Yes _____No _____Maybe/Unsure
Clinical Pathology? _____Yes _____No _____Maybe/Unsure
Other (specify) ______________________________________________________________________
Have you worked in the TNPRC now or in the past?
_____Yes _____No _____Maybe/Unsure
Have you previously worked with Burkholderia pseudomallei?
_____Yes _____No _____Maybe/Unsure
If yes, please explain on additional paper any possibly exposures.
Did you exit the vehicle while inside the facility?
Were you in the van driven by Van #1 or by Van#2 on day 1 (circle).
Did you tour the:
Area |
Yes/No |
Necropsy Anti-room |
|
Necropsy Suite |
|
Visit sample transfer area |
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Other Areas |
|
Did you touch any soil or water while on the tour?
Do you have any of the following chronic conditions that can increase your risk of disease from Burkholderia exposure?
Diabetes _____Yes _____No _____Maybe/Unsure
Chronic liver or kidney disease _____Yes _____No _____Maybe/Unsure
Alcohol abuse _____Yes _____No _____Maybe/Unsure
Hematologic malignancy
(blood cancers such as leukemia) _____Yes _____No _____Maybe/Unsure
Neutropenia or neutrophil dysfunction
(low white blood cell count) _____Yes _____No _____Maybe/Unsure
Chronic lung disease (asthma,
bronchitis, emphysema,
cystic fibrosis) _____Yes _____No _____Maybe/Unsure
Thalassemia _____Yes _____No _____Maybe/Unsure
Long-term steroid use _____Yes _____No _____Maybe/Unsure
Other form of immunosuppression _____Yes _____No _____Maybe/Unsure
Have you ever traveled or been deployed during military service to areas where Burkholderia pseudomallei occurs naturally, including:
Asia: Thailand, Laos, Singapore, Vietnam, Malaysia, Burma, Vietnam, Taiwan, China
Northern Australia
Africa: South Africa, Madagascar
Central, South America and Caribbean
Country |
Dates of Visit |
Working in Soil or Water |
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What animals do you have in your home or regularly interact with? If possible include species and numbers.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Bower, William (CDC/OID/NCEZID) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |