ࡱ> CEB bjbj:: (4PP88    8E$i\ #poC .0#CC8 :   Ƶ ANIMAL HANDLER HEALTH FORM - INJURY REPORT INSTRUCTIONS This form is to be completed and submitted to the person who is in charge of the laboratory animals or is supervising you in the handling of the wildlife animals with which you have had an accident. The supervising faculty/staff member must forward a copy of this report to the IACUC chairperson (Dr. Steven Threlkeld, Department of Psychology). DATE FORM COMPLETED : DATE OF THE INCIDENT ANIMAL HANDLER IDENTIFICATION Name: Department:Age: Ƶ Address:Telephone:E-mail: PRINCIPAL INVESTIGATOR: individual responsible for training and supervision Name:DepartmentOffice:Telephone: I have been apprised of the nature and severity of the injury and advised the student/staff member as to the proper procedure for treatment of the injury as appropriate. Supervisor Signature: Date TYPE OF ACCIDENT Briefly describe the accident, including animal(s) involved, drugs and/or chemicals involved, nature and severity of any injuries, etc. TYPE OF ACCIDENT, cont Is/are the animal(s) involved treated with any infectious agent(s)? Y / N If yes, what kind of agent? HISTORY Any known allergies to animals/insects or medications? YesPlease describe No TREATMENT INFORMATION: identify the health personnel who treated the injury if appropriate Name of Physician:Address:Address: Was Campus Police notified about the incident? Y / N If no, why not? Is there something that can be done to prevent reoccurrence of this type of incident? 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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