INSTITUTION AND CONTACT INFORMATION:
Institution
Respondent Name
E-mail / Phone
Would you like to receive e-surveys
in the future? / YES / NO
Date form filled in: (day/month/year)
ANIMAL INFORMATION: (Please circle, highlight or delete answers where appropriate)
Common Name
Genus / species / subspecies
ISIS or institutional ID number
Institution house name
Studbook number / Regional: Global:
Birth date:
(Day/month/year)
Gender / Female / Male / Unknown
Weight (in kg) at start of contraception? / actual / estimate
Date weight taken: (Day/month/year)
Has this individual ever had offspring? / Yes / No / Unknown
Date of most recent birth: (Day/month/year)
Mail or E-mail completed survey to:
Sally Boutelle, Wildlife Contraception Center, 1 Government Drive, Saint Louis, MO 63110 USA. Phone: 314-646-4595, Fax: 314-646-5534,
*Download an electronic version of this survey at
PRODUCT INFORMATION: (Please circle, highlight or delete answers where appropriate)Commercial name of the contraception product
MGA or Implanon Implant:
WCC Authorization or
Prescription (Rx) Number?
Weight of implant (grams)
Implant sterilization method?
Deslorelin Implant:
Dose / 4.7mg or 9.4 mg
Number of implants used
Supplemental contraception
used? / YES / NO
If no then: Was separation used? / YES / NO
If yes then: Name of the supplemental
product (e.g. Ovaban)
Dose (in grams)
Start date of supplemental
(Day/Month/Year)
End date of supplemental
(Day/Month/Year)
Injectable Contraception:
Route / SQ / IM / Dart IM
Location Given
Dose (e.g. 150mg)
Oral Contraception:
Brand name of the contraception
product?
If not a Birth control pill:What dose
(in grams) was used?
TREATMENT INFORMATION:(Please circle, highlight or delete answers where appropriate)
Start Date of most recent Bout
(Day/Month/Year)
Intended use of the contraception? / Contraception / Aggression / Supplemental to Deslorelin
Medical reason or Other (explain)
Route & Location of Product (e.g. SQ, intrascapular) / Subcutaneously / Intramuscular
Location:
DETAILS OF MATE ACCESS: During contraception if individual had access to opposite sex (mate)
Start date of mate access(after product started)
(Day/Month/Year):
End date of mate access
(Day/Month/Year):
OBSERVED BEHAVIOR:(Please circle, highlight or delete answers where appropriate)
Was copulation/intromission observed by staff prior to birth control? / YES / NO
Was copulation/intromission observed by staff after method started? / YES / NO
Did aggression change during treatment? / Decreased / Increased / No change
Weight Gain while on contraception? / YES / NO
Termination of Contraception Bout (circle, highlight or delete answers where appropriate)
Has the current bout been terminated (ended)? / YES / NO
If yes: please give date when bout ended or presumed expired
(Day/Month/Year)
How was the contraception bout terminated?
(please circle, highlight or delete answers where appropriate) /
- Animal Death
- Loss of Implant
- Discontinued contraception – removed implant/stopped treatment
- Replaced/changed contraception product (a new contraception bout begins when new implant/injection is given–fill out new form)
Why was contraception terminated? (Please circle, check, highlight or delete answers)
Animal Died – complete #1
Lost implant – complete # 2
Replaced/changed/removed – complete # 3
Individual was found to be pregnant – complete # 4
Individual was allowed to breed – complete #4 & 5
Management Decision (other than allowed to breed)
Medical Reason related or unrelated to contraception – complete # 6
Individual was transferred to an new institution – complete # 7
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DETAILS ON TERMINATION AND PREGNANCIES:#1Termination Due to animal death:
Date of death: / (Day/Month/Year)
Cause of death:
Any reproductive abnormalities at necropsy (describe):
#2 Termination due to lost implant:
Date lost: / (Day/Month/Year)
How was it determined that the implant was lost?
#3 Termination due to replaced/changed/removed implant:
Implant physically recovered? / YES / NO
#4 Individual was found to be pregnant:
Pregnancy planned or unplanned? / Planned or Unplanned
Date offspring born: / (Day/Month/Year)
Fate of the offspring: / Live / Stillbirth / Miscarriage
Abortion/miscarriage: approx age of fetus? (Days):
Was method confirmed in place at time of conception? / YES / NO / Assumed
Was method confirmed in place at time of birth? / YES / NO / Assumed
#5 Planned pregnancy (allowed to breed)
Date individual placed with mate for breeding? / (Day/Month/Year)
Date breeding attempted ended: / (Day/Month/Year)
If never become pregnant – suspected reason why?
#6 If the contraception was terminated due to medical reasons: Please give details:
#7 If transferred, was contraception in use at transfer? / YES / NO and PRESUMED / CONFIRMED
Transfer date: / (Day/Month/Year)
Transfer Institution Name:
Any Additional Comments: ______
______
Mail or E-mail completed survey to:
Sally Boutelle, Wildlife Contraception Center, 1 Government Drive, Saint Louis, MO 63110 USA. Phone: 314-646-4595, Fax: 314-646-5534,
*Download an electronic version of this survey at
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