MGA FEED

BI-ANNUAL SURVEY

Please complete the information below, using one form for each individual or group. If any adverse effects are noted, please write a separate report, including a signature, and mail to the address below.

· Date (e.g. 15 June 2006): __________________

· Institution: ______________________________________________________

· Institutional representative: _________________________________________

· E-mail address: ______________________ Phone number:_______________

· Genus:______________Species:____________Subspecies:______________

· Common name: __________________________________________________

If feeding in herd situation:

· Number of males: _________________ Number of females: ______________

If feeding individually:

· Individual ID#: ____________________ Name: ____________________

· Studbook #: _______________ Birthdate (e.g. 15 June 2006):______________

· Gender: female / male Weight: __________ lb or kg; actual or estimated

· Has individual ever had offspring? yes/no

· Date of most recent birth (e.g. 15 June 2006 ): __________________________

· Purina product code (Please circle): 5ZA4 or 5ZA5

· Dose _______________ lbs/animal/day

· Date feed was initiated (e.g. 15 June 2006): _________________________

· Did individual regularly eat entire ration? yes/no

· Did individual eat daily? yes/no

Mate access (during birth control):

· Start date (e.g. 15 June 2006): ________ End date: ______________

· Was copulation observed prior to contraception? yes / no

· Was copulation observed during contraception? yes / no

· Please note any behavioral or physical changes (like increased aggression, mating behavior, etc.): ______________________________________________

________________________________________________________________

· Was contraception terminated? yes/no

If so, date ended (e.g. 15 June 2006): __________________________

· Reason for termination:

· Medical___________________________________________________

· Changed to a different method_________________________________

· Other_____________________________________________________

· Reproduction/allow to breed (planned birth):

• Date placed with mate ___________________________________
• If successful, date offspring born (e.g. 15 June 2006):___________
• Fate of offspring: live birth / stillbirth / abortion
• If abortion - approximate gestational age of fetus_________

· Did an unplanned pregnancy occur? yes/no

If so, date offspring born (e.g. 15 June 2006):_______________________

Fate of offspring: live birth / stillbirth / abortion -

If abortion - please approximate gestational age of fetus_________

· Was the animal transferred?

If so, date (e.g. 15 June 2006):__________________________________

Name of receiving institution___________________________________

Contraceptive method in use when transferred? yes /no

· Animal death information (if applicable)

Date (e.g. 15 June 2006): _____________

Reproductive tract sent to Dr. Linda Munson? yes / no

Cause of death (if known) and any abnormalities noted at the time of necropsy:___________________________________________________

______________________________________________________________________________________________________________________

Additional comments:

Possible adverse effects or problems associated with contraceptive must be reported to the Wildlife Contraception Center in a separate report with an original signature

Submit forms to:

Sally Boutelle, Program Coordinator; Saint Louis Zoo; Forest Park - 1 Government Drive; St. Louis MO - USA 63110; 314-781-0900 ext. 384

Contraception@stlzoo.org