Farm Animal and Pet Glyphosate Exposure Survey Step 1 of 4 25% Please note: the Animal Glyphosate Exposure Survey is best taken on or near the date you collect a sample.Type of Animal*Select an OptionDogCatHorseCowPigGoatOther (answer below)Select an optionIf Other for Question 1 Name of Owner* First Last Email* Address* State / Province / Region ZIP / Postal Code PhoneDate Survey Completed* MM slash DD slash YYYY ANIMAL INFOBreed (i.e. Collie, Calico, pony, Holstein, mixed) ** Age*Approx Weight in lbs.*Gender*Select an OptionMaleFemale LIFESTYLE QUESTIONS WITHIN THE LAST 30 DAYS...How would you describe the area where the animal lives?*Select an OptionUrbanSuburbanRuralAre herbicides (weed killers) like Roundup® used in areas where the animal is active?*Select an OptionFrequentlyOccasionallyNeverI don't knowHas glyphosate drifted or run off adjacent property into areas where the animal is active?*Select an OptionFrequentlyOccasionallyNeverI don't knowIs the animal active on lawns where lawn care services apply chemical sprays?*Select an OptionFrequentlyOccasionallyNeverI don't knowIs the animal active on farms, golf courses, country clubs, cemeteries, school grounds, parks or other locations where herbicides are used?*Select an OptionFrequentlyOccasionallyNeverI don't knowDoes the animal live on or near a non-organic farm?*Select an OptionWithin 100 feetWithin 500 feetWithin 1/4 mileWithin 1/2 mileno DIETARY QUESTIONS WITHIN THE LAST 30 DAYS...What type of diet has the animal had in the last 30 days?*Select an OptionCompletely plant-based (such as horse or cow)Primarily meat-based (such as a cat's diet)Omnivorous (a mix of plants and meats, such as a dog eating kibble or raw meat and veggies)Is most of the water the animal consumed in the last 30 days:*Select an Optioncity/municipal waterwell watersurface water (stream or lake)spring waterfilteredbottledrain waterI don't knowWould you characterize the animal’s food in the last 30 days as:*Select an OptionCommercially processed pet food (e.g. kibble or canned foods)Raw or unprocessed pet food (e.g. raw chicken/beef/etc. with or without veggies)Whole cooked food (e.g. whole chicken/beef/veggies prepared at home)Mixed (e.g. for pets: some processed and some raw/for farm animals: grass fed and grain supplemented)Feed mix (e.g. feed mill or homemade mix fed to a horse or cow)Free-range (e.g. grass fed cattle)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)?*Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely of neverI don't knowNon-organic wheat, barley or rye (e.g. directly, or as an ingredient in kibble or treats, or bread and crackers)?*Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely or neverI don't knowNon-organic legumes (e.g. peas, pea protein, chick peas, lentils, etc. that are often used in grain-free foods)?*Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely or neverI don't knowNon-organic soy (e.g. soy protein, soy meal, or as an ingredient in kibble or treats)?*Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely or neverI don't knowNon-organic corn (e.g. directly, or as an ingredient in kibble or treats)?*Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely or neverI don't knowNon-organic potatoes or sweet potatoes (e.g. directly, or as an ingredient in commercially prepared food)?*Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely or neverI don't knowRoundup Ready® alfalfa?*Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely or neverI don't knowDog, cat, deer or other animal poop?Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely or neverI don't knowWhat percentage of the animal’s diet would you estimate is organic?*Select an OptionEvery day4-5 days per week2-3 days per week1 day per weekRarely or neverI don't knowTerms, Conditions and Consent Form* I agreeStandard 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.
