ࡱ> X[W{ ZKbjbjBrBr 4V  oL^ ^ 8\`f 2 >$) "r,QF  FF,4}FRF09-x^0M# M#M#FFFFFFF,,FFFFFFFM#FFFFFFFFF^ ~:  ʼһ State University Institutional Animal Care and Use Program Animal Worker Tetanus Immunization Certification ʼһ State University requires individuals who work with vertebrate animals to participate in a safety and health protection program prior to beginning work with the animals. All animal workers must be informed of known health and safety risks, trained in safety protections or practices, and provided with appropriate Personal Protective Equipment (PPE). Individuals working with animals that present no more than minimal risk of allergy/asthma development/exacerbation or of contracting zoonotic disease (disease capable of being transmitted from animal to human) are not required to participate in health screening but must have a current tetanus immunization. (Tetanus booster is required every ten years.) Reptiles, amphibians, and fish are considered to present no more than minimal risk. However, individuals with severe allergies, asthma, a compromised immune system, or any other significant health issue are strongly encouraged to seek advice from their health care provider prior to contact with any animal species. INSTRUCTONS: The Animal Worker should complete the Identification and Proposed Animal Activity sections below. The health care provider should complete the remainder of the form. (Student Health Services will complete this form for currently enrolled students.) The form should be returned to : Mailing Address: Hand Delivery Address: E-mail of Scanned Form: IACUC Administrator Office of Sponsored Programs & iacuc@valdosta.edu Office of Sponsored Programs & Research Administration (OSPRA) Research Administration (OSPRA) Psychology Building, Suite 3100 ʼһ State University ʼһ State University 1500 North Patterson Street ʼһ, GA 31698 Note that this form must be received by the IACUC Administrator prior to beginning work with animals or before continuing work with animals if your previous tetanus immunization has expired.  IDENTIFICATION (This section to be completed by the Animal Worker):Animal Worker Name:  FORMTEXT      ID (870) No:  FORMTEXT       Dept:  FORMTEXT      Supervisor:  FORMTEXT       FORMCHECKBOX  Full-Time Employee FORMCHECKBOX  Part-Time Employee FORMCHECKBOX  Grad Student FORMCHECKBOX  Undergrad Student PROPOSED ANIMAL ACTIVITY (This section to be completed by the Animal Worker):Indicate the type(s) of animals you do or will handle through your work at VSU (check all that apply): FORMCHECKBOX  Reptile (laboratory or field): Species (common name):  FORMTEXT       FORMCHECKBOX  Amphibian (laboratory or field): Species (common name):  FORMTEXT       FORMCHECKBOX  Fish (laboratory or field): Species (common name):  FORMTEXT      Briefly describe the nature, frequency, and proposed duration of your interaction with the animals:  FORMTEXT       TETANUS IMMUNIZATION (This section to be completed by the Health Care Provider): The date of the most recent Tetanus booster for the above named individual is: _______________Special NoELRSuvw+     9 < F 9 = ƹ{nanTTaTHhgh$h5CJaJhRh?CJ^JaJhRh!gkCJ^JaJhRh$hCJ^JaJhRhS_CJ^JaJhRCJ^JaJhRh;3CJ^JaJhRhRCJ^JaJhRh_CJ^JaJh$hh_CJ^JaJh`5CJaJhS_5CJaJhM5CJaJh 5CJaJh6h 5CJaJh`5CJaJEvw oZ $If^`gd4zkd$$Ifl+(,  t &0644 lap &yt4 $IfgdHpgd?$a$gd  A ̾{hTATh$h$hhHp>*B*CJPJaJph'h$hhHp5>*B*CJPJaJph$h$hhHp5B*CJPJaJph$h$hhHp5B*CJPJaJph!h$hh4B*CJPJaJphh$hB*CJPJaJph!h$hhHpB*CJPJaJphh?B*CJPJaJphh(gh(gCJPJaJ h hJh h PJhHp5CJPJaJh45CJPJaJ C#89{l $IfgdR $If^`gdR :$If^`gdR :X $If^`gdR :X $If^`gdR h$If^h`gdHp $IfgdHp Da"#894@~Ƕǣ~wodYdNhM5CJPJaJh#5CJPJaJh$h5CJPJaJh9Ih9I< h h4'h(gh(g5>*B*CJPJaJph!h$hhHpB*CJPJaJph$h$hhHp5B*CJPJaJph!h$hhHpB*CJPJaJph$h$hhR5B*CJPJaJph'h$hhR5>*B*CJPJaJph!h$hhRB*CJPJaJphw$&`#$/Ifgd#gd9Iskd$$Ifl +(, t0644 lap yt$h~ "$8:<FHۼۼpۼ\'jhshRCJPJUaJ'j;hshRCJPJUaJ,jhshRCJPJUaJmHnHu'jhshRCJPJUaJhshRCJPJaJ!jhshRCJPJUaJhshR5CJPJaJhR5CJPJaJhshMCJaJhshM5CJPJaJ!J$&`#$/IfgdR\kd@$$Ifl+(,  t 6` &644 lap &yt$hHJLdfz|~ !./0ʽʒʽʽ~tʽ`tʽLt'j 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