Animal Glyphosate Exposure Survey • Health Research Institute

Farm Animal and Pet Glyphosate Exposure Survey

Step 1 of 4

Please note: the Animal Glyphosate Exposure Survey is best taken on or near the date you collect a sample.
Type of Animal*
Select an option
If Other for Question 1
Name of Owner*
First Last
Email*
Address*
State / Province / Region ZIP / Postal Code
Phone
Date Survey Completed*
Date Format: MM slash DD slash YYYY

ANIMAL INFO
Breed (i.e. Collie, Calico, pony, Holstein, mixed) **
Age*
Approx Weight in lbs.*
Gender*

LIFESTYLE QUESTIONS WITHIN THE LAST 30 DAYS...
How would you describe the area where the animal lives?*
Are herbicides (weed killers) like Roundup® used in areas where the animal is active?*
Has glyphosate drifted or run off adjacent property into areas where the animal is active?*
Is the animal active on lawns where lawn care services apply chemical sprays?*
Is the animal active on farms, golf courses, country clubs, cemeteries, school grounds, parks or other locations where herbicides are used?*
Does the animal live on or near a non-organic farm?*

DIETARY QUESTIONS WITHIN THE LAST 30 DAYS...
What type of diet has the animal had in the last 30 days?*
Is most of the water the animal consumed in the last 30 days:*
Would you characterize the animal’s food in the last 30 days as:*
If you use commercially processed food or snacks, please name the brands and product names (i.e. Purina Pro Plan, chicken and rice kibble/ Buddy Biscuits, roasted chicken and peanut butter varieties)
Please estimate the percentage of total food consumed that is commercially processed:
If feeding non-commercial foods, please describe the food (i.e. whole chicken cooked at home / raw oats sourced from feed mill / etc.)
How often does the animal consume:
Non-organic oats (e.g. directly, or as an ingredient in kibble or treats)?*
Non-organic wheat, barley or rye (e.g. directly, or as an ingredient in kibble or treats, or bread and crackers)?*
Non-organic legumes (e.g. peas, pea protein, chick peas, lentils, etc. that are often used in grain-free foods)?*
Non-organic soy (e.g. soy protein, soy meal, or as an ingredient in kibble or treats)?*
Non-organic corn (e.g. directly, or as an ingredient in kibble or treats)?*
Non-organic potatoes or sweet potatoes (e.g. directly, or as an ingredient in commercially prepared food)?*
Roundup Ready® alfalfa?*
Dog, cat, deer or other animal poop?
What percentage of the animal’s diet would you estimate is organic?*
Terms, Conditions and Consent Form*
I agree
Standard Terms and Conditions:

By checking “I agree” in the study survey, I indicate that I have read the statement below and choose to enroll in this project. This authorization is equivalent to my signature.

Authorizations: I request, authorize and consent to laboratory testing. I understand that test results are strictly informational. Results should not to be used for diagnosis, monitoring, prevention or treatment of disease or impairment of, or the assessment of health. I understand that I should consult with my veterinarian if I have specific questions about my animal’s health. I authorize Health Research Institute (HRI) to contact me with study results and study updates.

Confidentiality: HRI regards confidentiality as the cornerstone of professional protocol. It is HRI's strict policy to release test results only to the contact person specified by the study participant for that test, and to no one else, unless we have received specific written instructions to do so. This Policy on Confidentiality applies both to test findings and to the names and personal information of all study participants.

Remedies: In the event of a material error by Health Research Institute (HRI) in the performance of analysis HRI’s sole obligation shall be for HRI to either (a) repeat the analysis at HRI's own cost, or (b) refund or credit the invoiced amount. In no event shall HRI Labs' liability in connection with any sale hereunder exceed the price paid for the service in issue.

Indemnification: I indemnify HRI and its directors, officers, employees, and agents from any loss, cost, damage or expense (including reasonable attorneys' fees) from any lawsuit, action, claim, demand or proceeding arising from or associated with, directly or indirectly, HRI’s execution and/or performance of its services.

Costs: Your decision to participate in the study is voluntary. There is a cost associated with participation. In general, each participant pays for the analysis of his or her own sample.

Farm Animal and Pet Glyphosate Exposure Survey

Step 1 of 4

Please note: the Animal Glyphosate Exposure Survey is best taken on or near the date you collect a sample.

ANIMAL INFO

LIFESTYLE QUESTIONS WITHIN THE LAST 30 DAYS...

DIETARY QUESTIONS WITHIN THE LAST 30 DAYS...

How often does the animal consume:

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