ANNUAL REVERSIBLE CONTRACEPTION
SURVEY
(INCLUDE ALL METHODS, EXCEPT
DESLORELIN)
*** PLEASE copy this
form. Use one sheet per animal per
implant, series of injections, etc. ***
INSTITUTION:
________________________________________________ DATE (M/D/Y): __________________
RESPONDENT:
_____________________________________PHONE/EMAIL _____________________________
=================================================================================================
ANIMAL
INFORMATION:
(Please circle answers where appropriate.)
GENUS
_______________SPECIES______________ SUBSPECIES ___________________
COMMON
NAME: _________________________________________________
ID#:
____________________ NAME:
____________________ STUDBOOK #:
_____________
BIRTHDATE
(M/D/Y): ______________ SEX: FEMALE /
MALE
WEIGHT:
__________ lb / kg (actual
/ estimate)
HAS
INDIVIDUAL EVER HAD OFSPRING? Yes / No
DATE OF MOST RECENT BIRTH (M/D/Y): _______________
=================================================================================================
METHOD: (Please circle answers where appropriate.)
IMPLANT: MGA IMPLANT INJECTION: DEPO-PROVERA ORAL: BC PILLS–BRAND________________
IMPLANON
LUPRON MGA LIQUID
OTHER: ____________ PZP OVABAN
OTHER: ____________ MEGACE
OTHER:____________
BIRTH
CONTROL START DATE (M/D/Y):
___________________
(the date when “this” bout/method was started)
MATE ACCESS (with birth control): START DATE (M/D/Y): ____________ END DATE (M/D/Y): _____________
DOSE: ___________ g / mg /
µg ROUTE: IM / SQ LOCATION ADMINISTERED: ____________________
================================================================================================
IF
MGA IMPLANT:
IMPLANT #: _____________
METHOD OF STERILIZATION: ETHYLENE OXIDE
OTHER: _________________
DID IT INCLUDE A MICROCHIP? YES /
NO WAS THE IMPLANT SUTURED IN
PLACE? YES / NO
=================================================================================================
WAS COPULATION OBSERVED BY STAFF PRIOR TO BIRTH
CONTROL? YES / NO
WAS COPULATION OBSERVED BY STAFF DURING BIRTH
CONTROL? YES / NO
FOR PRIMATES - SEXUAL SWELLING DURING BIRTH
CONTROL: ABSENT / NORMAL / REDUCED
PLEASE NOTE ANY BEHAVIORAL OR PHYSICAL CHANGES
® ®
® OVER ®
® ®
CONTRACEPTION
TERMINATED:
DATE ENDED (M/D/Y): _______________
Animal ID#_______________
IF
IMPLANTED (MGA OR IMPLANON), WAS THE IMPLANT(S) PHYSICALLY
RECOVERED/REMOVED? YES / NO
REASON FOR TERMINATION:
·
REPLACED/CHANGED METHOD:
Date___________ (This indicates the end of one contraceptive bout and
the start
of
another. Please fill out a blank
contraceptive form with the new contraceptive information.)
·
MEDICAL -
DETAILS: (Include
date)____________________________________________________________
·
LOST (Date _____________)
o CONFIRMED or PRESUMED
o
DETAILS:
____________________________________________________________________
·
REPRODUCTION/ALLOW TO BREED (planned
birth)
o DATE PLACED WITH MATE (M/D/Y):
____________
o IF SUCCESSFUL, DATE
OFFSPRING BORN (M/D/Y): ______________
o FATE OF OFFSPRING: LIVE
BIRTH / STILLBIRTH / ABORTION
§
IF ABORTION -
IF POSSIBLE PLEASE APPROXIMATE GESTATIONAL AGE OF FETUS ____________
·
OTHER -
DETAILS: (i.e. removed/transfer of mate)_______________________________________________
=================================================================================================
UNPLANNED BIRTHS: [Defined as a birth that was not planned (ie. contraceptive method was not purposefully ended for
reproduction).]
DATE
OFFSPRING BORN (M/D/Y): ______________
FATE
OF OFFSPRING: LIVE BIRTH / STILLBIRTH / ABORTION -
· IF ABORTION - IF POSSIBLE
PLEASE APPROXIMATE GESTATIONAL AGE OF FETUS ___________________
CONTRACEPTIVE METHOD CONFIRMED IN PLACE AT TIME OF
CONCEPTION? YES / NO
CONTRACEPTIVE METHOD CONFIRMED IN PLACE AT TIME OF
BIRTH? YES / NO
=================================================================================================
IF ANIMAL TRANSFERRED: DATE (M/D/Y): ________
NAME
OF RECEIVING INSTITUTION: ______________________________(please
include address if not AZA accredited)
CONTRACEPTIVE METHOD IN USE WHEN TRANSFERRED? YES / NO - PRESUMED / CONFIRMED
IF ANIMAL DIED:
DATE
(M/D/Y): _____________ REPRODUCTIVE
TRACT SENT TO DR. LINDA MUNSON? YES / NO
PLEASE
NOTE THE CAUSE OF DEATH (IF KNOWN) AND ANY ABNORMALITIES NOTED AT THE TIME OF
NECROPSY:
____________________________________________________________________________________________
____________________________________________________________________________________________
=================================================================================================
ADDITIONAL COMMENTS (For example, possible side-effects or problems associated with
contraceptive.):
MAIL
OR E-MAIL COMPLETED SURVEY FORMS TO:
Sally
Boutelle, Program Coordinator; Saint Louis Zoo;