INSTRUCTIONS FOR PARTICIPATION IN THE SIUC IACUC OCCUPATIONAL HEALTH PROGRAM
- Download a copy of the SIUC IACUC Medical History Form from the IACUC website , complete applicable areas and give to health care provider during your appointment.
- Areas to be completed on the SIUC IACUC Medical History Form
- Part A
- indicate whether faculty, staff, student or visitor
- fill in
- name
- social security number
- date
- address
- home and work telephone numbers
- department
- specie(s) of animal(s) your will be working with
- indicate month and year of any vaccinations or tests previously received
- Part B
- Schedule an appointment to receive a physical examination and appropriate immunizations/tests with either the Student Health Program at 453-3311 or your personal physician. If declining recommended vaccinations or tests, a Vaccine Declination Form must be completed. If using your personal physician, a copy of the Health Care Provider Instructions should be given the your health care provider during your appointment explaining the SIUC Occupational Health and Safety Program. Both the Vaccine Declination Form and the Health Care Provider Instructions are available from the IACUC website. The IACUC is not responsible for any charges incurred for the services or treatment received.
- Following the physical examination and receipt of appropriate immunizations/tests (or completion of Vaccine Declination Form), the health care provider will determine your medical status by checking the appropriate box, then sign and date the Medical History Form. You should read the completed Medical History Form, then sign and date the bottom of Part A.
- A copy of Part A of the Medical History Form and the Vaccine Declination Form (if used) should be given to you for return to the Office of the Laboratory Animal Program, Life Science III, Room 1062, MC 6506. Part B of the Medical History Form should not be copied because it contains confidential information that the IACUC is not privileged to have.