UNIVERSITY OF MINNESOTA Canine Epilepsy Research Project Consent Form DOG’S REG. NAME: DOG'S REG. #
BIRTHDATE:
The undersigned, who is the owner or co-owner (or owners or co-owners) of the above dog, agrees to participate in the above “Epilepsy Project” (as more fully defined below). The undersigned acknowledges that participation includes cooperation on the following: 1. Submission of copies of (a) the above dog's AKC registration certificate and 4-generation pedigree (or, alternatively, written authorization to the Epilepsy Project to obtain additional pedigree information about the above dog from the AKC) and (b) completed litter information forms and lists with respect to breedings of the above dog; 2. Transmission to the Epilepsy Project of blood and/or tissue samples (with tissue samples, however, only to be submitted after a dog is deceased); 3. Completion of a general health survey on the above dog and/or participation in a telephone interview (lasting approximately 20 minutes); and 4. Granting permission for the Epilepsy Project to contact the above dog's veterinarian regarding its health history. 5. There will be no compensation for participation in the study. Whenever possible we ask that you pay the cost of shipping, but we can cover shipping cost if needed - please contact us to arrange this. The undersigned acknowledges his, her, or their understanding that the “Canine Epilepsy Research Project” (sometimes herein “Epilepsy Project”) entails research to be carried out by the principal investigators at the University of Minnesota, pursuant to the research study that is more fully described in the abstract of this Consent Form, as well as that the study has been approved by, and is being funded by The American Kennel Club Canine Health Foundation or the Morris Animal Foundation. It is agreed that this “Epilepsy Project” may be expanded and/or supplemented in the future to include other research studies relative to epilepsy and that this Consent Form constitutes the undersigned’s approval of utilization of all submitted information. The undersigned further acknowledges that information provided to this “Epilepsy Project” will be made available solely to (a) the principal investigators for the Canine Epilepsy Research Project and their staffs (as well as, possibly, scientific investigators involved in epilepsy studies approved in the future by Funding Organizations and/or the AKC breed Parent Club) and (b) persons associated with the Parent Club who are working on this project and who are specifically approved to receive such information by the Parent Club Board of Directors. It is also understood that any publication for the public, resulting from this Epilepsy Project, will refer to individual dogs solely by an anonymous code.
Owner Name
Phone
Owner Signature
Date
UNIVERSITY OF MINNESOTA Canine Epilepsy Research Project Individual Dog Questionnaire
(For seizing and non-seizing dogs)
Litter ID Code
Dog Information Breed
Call name
Registered Name
Birth Date
Registration #
Date of Death
Sire
Sex If neutered/spayed, at what age
Dam
Country of Origin
Type/Usage
Owner Information Name
Phone
Street Address
Alternate Phone
City, State, Zip
Fax
Country
e-mail
Does this dog exhibit any of the following conditions? (Attach particulars for any Yes answer) Yes
No
Aggression
Yes
No
Heart problems (specify)
Yes
No
Allergies
Yes
No
Yes
No
Arthritis
Yes
No
Hernia (where?) Reproductive disorders
Yes
No
Autoimmune disorders
Yes
No
Yes
No
Bleeding disorders
Yes
No
Cancer/ Tumors
Yes
No
Skin/ Coat problems
Yes
No
Deafness / Hearing impairment
Yes
No
Structural abnormalites(hip/elbow dysplasia)
Yes
No
Ear infections
Yes
No
Other (specify:
Yes
No
Eye diseases / problems (specify)
Yes
No
Other (specify:
Seizures/Epilepsy (If yes, please also complete the seizure survey)
Testing done on this dog: OFA/PennHIP
Yes
No
age at test:
results
#
ACVO exam
Yes
No
age last tested:
results
#
Thyroid
Yes
No
age last tested:
result
age at last test:
result
age at last test
type of test
Allergy
Yes No Heart Yes No Other (please attach separate sheet)
result
UNIVERSITY OF MINNESOTA Canine Epilepsy Research Project
Litter ID Code
Litter Information (if applicable) (Attach Pedigree, and Litter List)
Litter birthdate
Breeder(s)
Phone
Street Address
Alternate Phone
City, State, Zip
Fax
Country
e-mail
Sire
Sire Reg. #
Dam
Dam Reg. #
Age of parents at breeding:
Sire
Dam
This litter resulted from (check all that apply): Chilled semen Natural breeding
Frozen semen
Artificial Insemination
Surgical Insemination
Number of pups: M
F
Surviving at 6 weeks:
M
F
•
Surviving at 1 year
M
F
•
Surviving at submission date
M
F
•
At birth:
•
Live
Dead
M
F
Known health problems in litter (list problem, dog name & Litter ID Code from Litter List, age of onset of problem, and pertinent details). Please attach additional sheets if necessary.
Other litter notes or comments, attach additional sheets if necessary.
UNIVERSITY OF MINNESOTA Canine Epilepsy Research Project Litter List Sire
Litter ID Code
Dam
Litter birthdate
1. Reg. #
Reg. Name
Sex
2. Reg. #
Reg. Name
Sex
3. Reg. #
Reg. Name
Sex
4. Reg. #
Reg. Name
Sex
5. Reg. #
Reg. Name
Sex
6. Reg. #
Reg. Name
Sex
7. Reg. #
Reg. Name
Sex
8. Reg. #
Reg. Name
Sex
9. Reg. #
Reg. Name
Sex
10. Reg. #
Reg. Name
Sex
11. Reg. #
Reg. Name
Sex
12. Reg. #
Reg. Name
Sex
13. Reg. #
Reg. Name
Sex
14. Reg. #
Reg. Name
Sex
15. Reg. #
Reg. Name
Sex
16. Reg. #
Reg. Name
Sex
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