High Point University
Animal Handler Medical Surveillance Certification Form
This letter is to certify that
has fulfilled the annual medical
evaluations portion of the High Point University's Assurance of Compliance with the National institutes of
Health’s Office of Laboratory Animal Welfare.
Based on my evaluation on
, I have/ have not (circle one) detected
medical conditions which would place this employee at increased risk of material impairment of health from
handling laboratory animals.
The employee has been informed of the results of the medical examination and of any conditions
resulting from animal handling.
The employee has also been instructed of any further examinations which may be required.
All employees reporting tobacco use have been informed of the potential increased risk they have of
developing animal allergies by smoking tobacco
The complete examination form for this employee is on file in the office noted below.
Date:
Examining Provider's Signature:
Examining Provider's Printed Name:
Examiner's Address:
Please forward a completed copy to attn.: Vice President of Facilities and Auxiliary Services, Drawer 52, High Point
University, 833 Montlieu Avenue, High Point, NC, 27268-0001 and Mr. Tim Linker, Director of Research Administration and
Sponsored Programs Drawer 66, High Point University, 833 Montlieu Avenue, High Point, NC, 27268-0001