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Confidential Medical Information for Personnel Working with Research Animals Medical Surveillance Questionnaire
All fields are required. Put N/A or NONE where you don't have an answer.
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Today's Date
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MM
/
DD
/
YYYY
Your Name:
*
Your answer
Date of Birth: (format 01/01/1993)
*
Your answer
Sex:
*
Male
Female
Email Address (use IU email address if you have one):
*
Your answer
Supervisor/Sponsor
*
Your answer
IU Department:
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Your answer
Department Address:
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Your answer
Department City:
*
Your answer
Department State:
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Your answer
Department ZIP:
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Your answer
Home or Cell Phone:
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Your answer
Medication or Latex Allergies?
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Your answer
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