ࡱ> []Z  bjbj:: (TPP$88III]]]]84]!'mmbbb&&&&&&&#)+&Ib^bbf&n&nnnj8I&nb&nnr"T1Il#$]]"#<&0!'"zS,nS,l#nIl#bbb8 :   Ƶ Animal Handler Documentation Completion of this form is a required component to your training in animal handling at Ƶ. All health documentation paperwork MUST be completed PRIOR to handling of live animals for teaching or research purposes. Complete and submit the Animal Handler Health Document to the College Health Services (pages 2 &3). Should an injury or illness resulting of animal handling activity occur, you must complete an Animal Handler Health Form Injury Report available on Forms page on the IACUC website. Minor medical treatment can be provided at College Health Services. If you require a tetanus booster (good for ~10 years), you may make an appointment at the Health Center to receive an immunization. Please have your supervising faculty member complete the bottom portion of this form. You must attach this sheet to the certificate of training document upon completion of the online training module and submit it to the IACUC chair (Dr. Steven Threlkeld) to complete the mandated training process. Failure to comply with these requirements may result in IACUC intervention and cessation of your participation in animal activity at Ƶ. PRINCIPAL INVESTIGATOR (individual responsible for training and supervision) Name:DepartmentOffice:Telephone: Name of Animal Handler who will be working under my supervision: I have reviewed all relevant safety and security measures related to animal utilization. This individual has been fully informed of any potential risks and hazards and has been made aware of safety and emergency measures as appropriate to the work they will be completing under my supervision. Supervisor Signature: Date: Ƶ ANIMAL HANDLER HEALTH DOCUMENTATION INSTRUCTIONS This form is to be completed and submitted to College Health Services. If a significant change in health status occurs while you are completing animal-related activity such as pregnancy or serious illness resulting in immunosuppression, please consult your physician to determine if your participation in animal handling activities should be modified. DATE: (keep on file for three years from this date) IDENTIFICATION Name: Department:Age:Sex: M / F Height:Weight:Ƶ Address:Telephone:E-mail: MEDICAL HISTORY Date of last tetanus booster:Known allergies: Are you presently taking any medications? Y / NIf yes, please list Name of physician:Telephone:Address:Person to contact in case of emergency:Telephone:Relationship to student:Address:Have you ever had: Please indicate Y for Yes or N for No after each item. Diabetes Heart DiseaseAnaphylaxisKidney DiseaseHepatitisEpilepsySalmonellosisEncephalitisAsthmaMeningitisChronic Respiratory Disease ANIMAL EXPOSURE Do you maintain personal pets in the home or campus environment? Y / N If yes, what species? Any known allergies to animals or insects? Y / N If yes, please describe. List the species with which you will be working in the lab/field environment: List known hazardous chemicals with which you will be working as a component of the required animal handling activity: In certain instances, laboratory tests may be indicated in order to work with certain species. Blood and/or urinalysis may be requested at a later date. VERIFICATION The undersigned verifies that the above is complete and true, and understands that further information and/or testing may be required. 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Courier New;Wingdings"1h,g$,Ѧ 'F h 4d  2qHX?Q2VILLANOVA UNIVERSITY VillanovaUser Support Services     Oh+'0  ,8 \ h t 'VILLANOVA UNIVERSITY Villanova Normal.dotmUser Support Services10Microsoft Macintosh Word@_@K}@R @>'F /_layouts/15/DocIdRedir.aspx?ID=67Z3ZXSPZZWZ-509-10, 67Z3ZXSPZZWZ-509-10'Test ?@ABCDEFGHIKLMNOPQpTUVWXYc\_b`awdefghijklmnoxyz{RRoot Entry F?5^@Data +1Table3o,WordDocument(TSummaryInformation(JDocumentSummaryInformation8-TCompObj`MsoDataStore ?5?5  "#$&'(*+,./0123456789:<>?@ F Microsoft Word 97-2004 DocumentNB6WWord.Document.8Document ID GeneratorSynchronous100011000Microsoft.Office.DocumentManagement, Version=15.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429cMicr3A3EISZU1HJ==2 ?5?5Item  PropertiesFRX3GYU0BX==2 ?5?5Item  !Properties%MFRI0FUEA==2?5?5Item S'Properties)2SPP1ESF1DXQ==2?5?5Item ;Properties=osoft.Office.DocumentManagement.Internal.DocIdHandlerDocument ID GeneratorSynchronous100021001Microsoft.Office.DocumentManagement, Version=15.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429cMicrosoft.Office.DocumentManagement.Internal.DocIdHandlerDme="_dlc_DocId" ma:index="10" nillable="true" ma:displayName="Document ID Value" ma:description="The value of the document ID assigned to this item." ma:internalName="_dlc_DocId" ma:readOnly="true"> This value indicates the number of saves or revisions. 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