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Annual Immunocontraception Data Sheet
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Annual Immunocontraception Data Sheet
If you are human, leave this field blank.
Submit this form after first series of inoculations, and every year after booster during trial.
Zoo Information
Zoological Garden
*
Animal Information
Species
*
ID/ISIS
*
Birth Date
*
Weight (KG)
*
Previous Reproductive History
Date of Birth
Note
Date of Birth
Note
Date of Birth
Note
Date of Birth
Note
Date of Birth
Note
Inoculation History
Inoculation 1
Inoculation Date
PZP Dose (µg) / lot #
The standard dose is 100µg unless you were otherwise notified.
Adjuvant
FIA
MFA
Means of Administration
Select Type
Hand Injection
Pole-syringe
Dart
Injection Site
Where the injection was administered, either right or left
Inoculation 2
Inoculation Date
PZP Dose (µg) / lot #
Adjuvant
FIA
MFA
Means of Administration
Select Type
Hand Injection
Pole-syringe
Dart
Injection Site
Inoculation 3
Inoculation Date
PZP Dose (µg) / lot #
Adjuvant
FIA
MFA
Means of Administration
Select Type
Hand Injection
Pole-syringe
Dart
Injection Site
Inoculation 4
Inoculation Date
PZP Dose (µg) / lot #
Adjuvant
FIA
MFA
Means of Administration
Select Type
Hand Injection
Pole-syringe
Dart
Injection Site
Inoculation 5
Inoculation Date
PZP Dose (µg) / lot #
Adjuvant
FIA
MFA
Means of Administration
Select Type
Hand Injection
Pole-syringe
Dart
Injection Site
Concurrent Drug Use
Any other Pharmaceuticals used during the course of study
Drug Name
Dose
Dates of Administration
Drug Name
Dose
Dates of Administration
Drug Name
Dose
Dates of Administration
Post Inoculation Reproductive History
If any offspring were born, describe their general health.
Date of Birth
Note
Date of Birth
Note
Date of Birth
Note
Date of Birth
Note
Date of Birth
Note
Post-Treatment Behavioral/Clinical Signs of Estrus
Date
Note
Date
Note
Date
Note
Date
Note
Date
Note
Problems
Describe Any Pre-Treatment Health Problems
Describe Any Post-Treatment Health Problems
Describe Any Unusual or Unexpected Post-Treatment Behavioral Displays or Problems
Males
Describe any dates when male was removed, separated and/or introduced. If any offspring were born, describe their general health.
Date
Note
Date
Note
Date
Note
Date
Note
Date
Note
PZP Treatment Discontinues
If PZP Treatment Is Discontinued Please State Reason Including Planned Reversal
Additional Information
Additional Remarks
Note: If any treated animal is transferred to another zoo, please note location on Data Sheet
Verification
Verification
*
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Submit
Elephants
Make sure to read our booklet on free-ranging African Elephant Immunocontraception!
Read It Now
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