HR Biosecurity Questionnaire

HR BIOSECURITY QUESTIONNAIRE

Purpose: This Biosecurity Questionnaire collects information necessary to assess occupational biosecurity risk, determine training and access requirements, and document consent for legally permitted background and health-related inquiries. Responses are confidential and used only for employment suitability, safety clearance, infection control, and compliance with applicable institutional policies. False statements, omissions, or failure to disclose information material to biosecurity may result in disciplinary action, denial of access, or termination.

Personal Information

Position Information

Employment History

Most Recent Employer

Previous Employer

Education and Training

Professional References

Reference 1

Reference 2

Reference 3

Biosecurity and Health Questions

1. Have you worked in a laboratory, animal facility, clinical setting, or other environment where you handled or were routinely exposed to biological agents, recombinant materials, animals, or human-derived materials? Yes No

2. Have you received immunizations or prophylactic treatments required for work with biological agents (for example, required occupational vaccines)? Yes No

3. Do you have any medical condition, immune compromise, or use any medication that may affect your ability to follow personal protective equipment (PPE) or other safety protocols? Yes No

4. In the past 30 days, have you traveled to regions with known infectious disease outbreaks, or had close contact with individuals confirmed to have a communicable disease relevant to this role? Yes No

5. Have you ever experienced an occupational exposure incident (e.g., needlestick, mucous membrane exposure, uncontained release) involving a biological agent? Yes No

6. Have you been the subject of action, restriction, or disciplinary finding related to biosafety or biosecurity practices at any current or former employer? Yes No

7. Will your duties require access to secured laboratory areas, select agent inventories, animal housing, or patient specimens? Yes No

Training, Policies, and Acknowledgements

I acknowledge that if employed or granted access, I must complete all required biosecurity and biosafety training prior to unsupervised access. Failure to complete training or follow required protocols may result in restricted duties or loss of access.

Equal Opportunity and At-Will Statement: Acknowledgement of equal employment opportunity and, where applicable, at-will employment status. This questionnaire is not an employment contract and does not alter the at-will relationship unless a separate written agreement states otherwise.

Authorization and Privacy Notice

By signing below, I authorize the organization to verify the information I have provided, contact listed references and prior employers, and request or obtain records necessary to evaluate biosecurity risk and eligibility for access. Where permitted by law, this may include background checks, verification of training and credentials, and limited health-related inquiries to determine fitness for specific duties. The organization will handle medical and health information in accordance with applicable privacy laws and institutional policy.

Applicant Certification

I certify that the information provided on this form is true, correct, and complete to the best of my knowledge. I understand that omission or misrepresentation of material facts may disqualify me from employment or subject me to termination. I agree to promptly report any changes to the foregoing information that may affect my biosecurity status or access.

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