Part A. SVSU IACUC Medical History Form
Science West Animal Facility
This form is required as part of the Occupational Health and Safety Program at SVSU for personnel who
have contact with animals used for research, teaching or testing. This Medical History Form must be
updated every 6 years.
Name
(Last)
Local Address
(Street)
Department
ID#
(First)




Faculty
Student
Staff
Visiting
Researcher
Date
(Middle)
Home Phone
(City)
(State)
Responsibility in lab
Animal species I will work with are: rats, mice, frogs, fish
Work Phone
(circle appropriate choices)
Note: rats and mice are purchased from a certified research animal model providers, frogs are purchased from scientific supply
companies, fish are purchased from scientific supply companies as well as local pet stores.
Allergic reactions to Rodents: Personnel working with laboratory rodents are exposed to rodent dander, hair,
skin, fur, saliva and body waste, urine in particular, which contain powerful allergens affecting skin and
respiratory systems. Personnel working with laboratory rodents incur an occupational risk of developing
allergies and having allergic reactions. Those personnel which have other allergies are at greater risk. The
primary symptoms of an allergic reaction are nasal or eye symptoms, skin disorders and asthma.
Personal Protective Equipment: Personnel working with the laboratory rodents are required to wear a
disposable lab coat, gloves, and a dust mask at all times as well as goggles when appropriate when in the animal
care facility.
Tasks: Personnel (for those working with the animal species mentioned above) in the Biology Department may
include the following tasks:
– proper handling of laboratory rodents, frogs and/or fish
– cleaning rodent cages which includes removal of used bedding, manual washing of the cage and replacement of the bedding
– manual washing of rodent cage lids, water bottles and sipper tubes
– handling and washing of 10 gallon aquaria
– handling and washing of half-gallon sized plastic cages for frogs
– filling water bottles and food bins
– checking on the health of the laboratory rodents, frogs and/or fish by viewing them in place within their cages
– lifting bags of food and bedding (50 lb maximum) 40 inches maximum into a wheeled container
– transporting cages of animals using a cart
– sweeping and mopping floors, including filling and dumping of water from the mop bucket
– washing walls and ceilings using a telescoping mop and squeegee (ladders not used)
– removal of waste contained in plastic bags to an outdoor dumpster using a cart (bags would be lifted onto the cart and lifted into the
dumpster)
Required vaccination: Tetanus Diphtheria (TD)
Mo/Year
Medical Evaluation to be completed by the physician
I have evaluated the medical status of this individual and there…Check one box below:
☐are some medical conditions that would place this individual at risk (please note accommodations under
“comments” below). If noted tasks and/or animals can be eliminated from this individual’s duties (for example, lifting
50 lb bags, not handling frogs), they may still participate.
☐are sufficient medical conditions that would place this individual or the laboratory animals at risk that he/she should
not work with the specified animals.
☐are no medical conditions that would place this individual at risk if he/she is in contact with the listed laboratory
animals performing the tasks listed above nor does he/she have a medical condition that may compromise the health
status of the laboratory animals.
I have advised the individual that the TD vaccination is required to work with the species of animals listed above. This
individual has received the vaccination indicated above.
Comments:
(Physician’s signature, printed name and address)
(Date)
To be filled out by the individual (faculty, staff or student):
To my knowledge I have no medical condition that would be aggravated by my contact with laboratory animals nor do I
have an illness that would be deleterious to the laboratory animals. I understand that it is my responsibility to return a
completed copy of Part A only of this form to: Kathleen Pelkki, Science West 159, 7400 Bay Road, University
Center, MI 48710, for IACUC records prior to beginning any work with animals. My signature below is my approval to
give a copy of this form to IACUC.
(Faculty, staff or student personnel signature)
(Date)
Part B. PERSONAL HEALTH HISTORY
(Note: to be filled out by personnel to give to the doctor/ health care provider)
1. Infections and allergies can place you and/or the laboratory animals at risk for health problems. Do you have any of the
following conditions?
Yes
No
Explain
Yes
1. Asthma
6. Bronchitis
2. Hay fever
7. Pneumonia
3. Sinus infection
No
Explain
8. Tuberculosis
4. Animal
allergies
9. Chronic diarrhea
5. Other allergies
10. Other infections/
contagious diseases
2. Physical limitations may interfere with your ability to lift cages or other equipment and supplies, to stand for long periods
of time, to visually monitor the animals or to handle aggressive animals. Do you have any of the following conditions?
Yes
No
Explain
1. Back problems
2. Tendon, ligament or joint problems
3. Shortness of breath on exertion
4. Heart problems
5. Visual limitations
6. Major surgery complications
3.
Pregnant women need to be careful when coming into contact with some species of animals. Are you pregnant? Yes
4.
Do you have any of the following conditions that might place you at risk when working around equipment or animals?
Yes
No
No
Explain
1. Dizziness
2. Severe headaches
3. Insulin dependent
diabetes
5. Are you currently taking medications or are you under a doctor's care for any other medical conditions that have not been
asked about? Yes
No
if yes, explain: