•	Faculty
•	Student
•	Staff
•	Visiting Researcher

Part A. SVSU IACUC Medical History Form – 
HHS Vivarium 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	ID#	Date	
           (Last)                           (First)                     (Middle)			
Local Address	Home Phone		
           (Street)                         (City)                       (State)			
Department                                 Responsibility in lab	Work Phone		

Animal species I will work with are:  rats	mice   (circle appropriate choices) 
Note: these animals are purchased from a certified research animal model provider, such as Charles River.

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 who 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 lab coat, gloves, and a dust mask as well as goggles, when appropriate, in the animal care facility.

Tasks: A lab/research assistant position (for those working with the animal species mentioned above) in the College of Health and Human Services may include the following tasks:  
– proper handling of laboratory rodents
– cleaning cages which includes removal of used bedding, automated washing of the cages, and replacement of the bedding
– Placing cage lids, water bottles and sipper tubes into the cage washer
– filling water bottles and food bins
– checking on the health of the laboratory rodents 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 (step ladders)
– 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:

(Health Care Provider/Physician’s signature, printed name and address)						(Date)

To be filled out by personnel:

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 this form to: (Julie Decker, IACUC Administrator, Zahnow 228,) 7400 Bay Road, University Center, MI 48710, for IACUC records prior to beginning any work in the lab 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)

2.  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	No	Explain	

 1.  Asthma	

6.  Bronchitis			

 2.  Hay fever	

7.  Pneumonia			

 3.  Sinus infection	

8. Tuberculosis			

 4.  Animal allergies	

9.  Chronic diarrhea			

 5.  Other allergies	

10. Other infections/
contagious diseases			

3.	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	

	

4.	Pregnant women need to be careful when coming into contact with some species of animals.  Are you pregnant?  Yes _____  No _____

5.	Do you have any of the following conditions that might place you at risk when working around equipment or animals?

	Yes	No	Explain	

 1.  Dizziness	

	

 2.  Severe headaches	

	

 3.  Insulin dependent diabetes	

	

6.  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: