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Elephant Serum Bank Submission Form

Elephant Serum Bank Submission Form 

Institution/owner: _____________________________________________________

Submitter:    _____________________________________________________

Address:  _____________________________________________________    _____________________________________________________

Tel: _________________ Fax:  _____________  Email:  ______________________

Animal Information

Asian  [  ]     African  [  ]               ISIS#  ____________  Studbook #  ______________

Name  ______________________      Age: _________  [  ]  actual  [  ]  estimate

Sex: [  ]  male    [  ]  female

SAMPLE COLLECTION INFORMATION

Date of sample collection:  ___________ Time of collection :  __________

Site of sample collection:  [  ]  ear vein  [  ]  leg vein  [  ]  other:  ___________

Health status of animal:  [  ]  normal  [  ]  abnormal

Fasted:  [  ]  no  [  ]  yes – how long  ______________ 

Weight  ________________  [  ]  actual   [  ]  estimated

Type of restraint:  [  ]  manual   [  ]  anesthetized/sedated  [  ]  behavioral control

Temperament of animal:  [  ]  calm  [  ]  active   [  ]  excited         

Type of blood collection tube: 

[  ]  no anticoagulant (red-top) 

[  ]  EDTA (purple)

[  ]  heparin  (green)  

[  ]  other:  ___________________

Sample handling:   [  ]  separation of plasma/serum by centrifugation 

(check all that apply) [  ]  stored as whole blood 

            [  ]  frozen plasma/serum

            [  ]  other – describe  _______________________ 

TB EXPOSURE STATUS

[  ]  Known infected animal

[  ]  Known exposure to culture positive source within the past 12 months

[  ]  Known exposure to a culture positive source within the past 1-5 years

[  ]  No know exposure to a culture positive source in the last 5 years  

TREATMENT INFORMATION

Is elephant currently receiving any medication or under treatment?  [  ]  yes   [  ]  no

If yes, please list drugs and doses:  ____________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Time between blood collection and last treatment:  _________________________

 

Ship samples overnight frozen with shipping box marked "PLACE IN FREEZER UPON ARRIVAL” 

Send completed form with samples to:

Dr.  Michele Miller

Disney’s Animal Kingdom-Dept. of Vet. Services

1200 N. Savannah Circle East

Bay Lake, FL  32830

(407) 939-7316; email:  Michele.Miller@disney.com


 

Consent Form for Use of Serum by Elephant SSP 

I give consent for the serum submitted to the Elephant Species Survival Plan (SSP) serum bank to be used for research on any elephant related issues based on recommendations by the veterinary advisor and/or steering committee. 

The results could be reviewed and used by the SSP veterinary advisor in providing health-related recommendations and publications. 

I understand that all results and recommendations regarding the individual elephant will be kept confidential. 
 
 

_____ Yes, I agree to allow the SSP to use our sample for designated research and testing results. 
 

_____ No, I do not consent to the use of our sample and test results unless specified. 
 
 
 
 

__________________________________________  __________

Signature, title         Date 
 
 
 

___________________________________________________  _________________________

Printed name       Phone number 
 
 
 

____________________________________________________  _________________________

Institution       Email address 
 

____________________________________________________

Address 
 

____________________________________________________ 
 
 

____________________________________________________ 
 
 

Comments:  ___________________________________________________________

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