Saint Louis University
Occupational Health Program for Laboratory and Animal Research
MEDICAL SERVICES DECLINATION FORM
Only Complete and Sign This Form if You Are Declining Medical Services in the Saint Louis University
Occupational Health Program for Laboratory and Animal Research
The University and applicable research compliance committees (IACUC, IBC; RSC) must be assured that you are aware of the
potential hazards associated with having contact with pathogens, recombinant DNA, and/or laboratory animals. Per University policy
(RC-006), University personnel exposed to these hazards are required to participate in the Occupational Health Program for
Laboratory and Animal Research (OHP). Persons required to participate in the OHP may decline the medical services component of
the program. If you choose to decline the medical services, you are required to agree to the following:
1. I have been informed about the real and potential hazards associated with working with pathogens, recombinant DNA, and/or
laboratory animals.
2. I attest that: (Check one)
I work with laboratory animals under Animal Use Protocol # _________________;
AND I have been informed of the Saint Louis University Occupational Health Program;
AND I have had the opportunity to read the document “Safe Handling of Laboratory Animals.”
I do not work with laboratory animals.
3. I knowingly decline the medical services offered in the Saint Louis University Occupational Health Program for Laboratory and
Animal Research. I understand declining medical services could lead to, among other things, increased risk for health
complications, inability to receive reimbursable care, and the need to secure my own alternate care provider for occupational
health services.
4. I realize that declining the medical services of the Occupational Health Program may preclude me from some positions that
require evaluation and preventative medical care.
IN SIGNING THIS FORM, I ACKNOWLEDGE AND REPRESENT THAT I have read the above Agreement, that I understand all
its provisions, and I sign it voluntarily as my own free act and deed. I warrant that no oral representations, statements, or inducements,
apart from the foregoing written agreement, have been made.
__________________ ____________________________ _________________________________
Date OHP Participant (print) OHP Participant (signature)
If Participant is Under 18 Years of Age
__________________ ____________________________ _________________________________
Date Parent/Legal Guardian (print) Parent/Legal Guardian (signature)
Last Four Digits of Social Security#: XXX-XX- __ __ __ __
Date of Birth _________________ Contact Phone Number: (____) ____-______
Email Address: ___________________________________________________________
Instructions to Submit: Return completed form to Employee Health. It is best to use the secure confidential fax: 314-268-5.
You can keep the original for your own records after you check the fax confirmation from your machine. Alternatively, the form can
be interoffice mailed to Employee Health. It is still recommended that you keep a copy for your own records.
FORM VERSION 5 (06MAY2014)
