EEHV HD Emergency Assistance Request
Please include answer all questions completely in order to expedite response.
Facility/Contact Information
Facility Name
*
Primary Contact Name
*
First Name
Last Name
Primary Contact Job Title
*
Primary Contact Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Email Address
*
example@example.com
Secondary Contact Name
*
First Name
Last Name
Secondary Contact Job Title
*
Secondary Contact Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Email Address
*
example@example.com
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Resource Requests
Do you need medications, supplies, blood products, etc.?
*
Yes
No
Maybe
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Supply Requests
What supplies do you need (select all that apply)?
*
Famciclovir
Ganciclovir
Zelnate immunostimulant
Blood collection bags
Plasma transfer bags
Metal line clips
Blood transfusion administration sets
Blood product
LeukoTic/Leukopet kits
Other
Is your institution okay with receiving expired drugs?
*
Yes
No
N/A- only want blood product
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Supply Requests
What blood products would you prefer to receive (check all that apply)?
*
Whole blood
Penciclovir-fortified whole blood
Fresh plasma
Frozen plasma
Penciclovir-fortified plasma
Is your elephant crossmatched to elephants at another facility?
*
Yes
No
Which facilities have you crossmatched with previously?
*
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Supply Shipping Information
Please include the specific shipping information required to get the supplies shipped to the correct location, and all shipping account numbers and specific instructions.
Preferred Shipping Company
*
FedEx
UPS
Other
Shipping Destination
*
Ship to Facility
Ship to UPS/FedEx office
Ship To Name
*
First Name
Last Name
Facility Ship To Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
UPS/FedEx Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Shipping Company Account Number
*
Additional Shipment Info (Reference # for memo line, etc.)
*
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Personnel Requests
Do you need any on-site personnel assistance (select all that apply)?
*
Veterinarian to assist primarily with EEHV case
Veterinarian to assist primarily with other cases on zoo grounds
Veterinary technician to assist primarily with EEHV case
Veterinary technician to assist primarily with labwork, include crossmatching
Veterinary technician to assist primarily with other cases on zoo grounds
Elephant manager/husbandry staff with previous EEHV treatment experience
Elephant manager/husbandry staff to help clean barns/exhibits
None of the above
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Personnel Requests
Does your facility require that responding personnel be N95 fit-tested or TB tested?
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Yes, TB tested
Yes, N95 fit-tested
Yes to both
No to both
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Personnel Requests
Does your facility have any housing options for responding personnel (select all that apply)?
*
Housing with staff members
Housing on zoo grounds
Discount pricing with nearby hotel
None of the above- responding personnel will need to make their own hotel reservations
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Personnel Requests
Do you need any remote personnel assistance (select all that apply)?
*
Yes- Veterinarian
Yes- Veterinary Technician
Yes- Elephant husbandry
No
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Financial Reimbursement
Is your facility willing to reimburse for shipping and/or travel costs incurred with EEHV response (please select one)?
*
Yes, shipping costs only
Yes, travel costs only
Yes, both shipping and travel costs
No
Other
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Additional Requests/Information
Please provide any other information that you think would be helpful in getting assistance to you as quickly as possible.
*
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