AZA AVIAN INFLUENZA VACCINATION STUDY PARTICIPATION
SIGN-UP
Name of institution: _______________________________
Address of institution: ___________________________________________________
___________________________________________________
Institutional Agreement
Agreement to participate in the avian influenza vaccine trial as outlined. In addition, we
agree that the data is the property of the AHC/AZA and can be used as needed for
publication. The participating institutions relinquish ownership rights to any data
accumulated in the process of project guidelines.
CEO/President: _____________________________________
General Curator: ___________________________________________
Veterinarian: ________________________________________
IACUC approval: ____________ Date: ___________________
Contact individual: _____________________ PH: _________________________
E-Mail: _______________________________
Return To:
Gary Riggs DVM
Akron Zoological Park
Fax: 330-825-0090
glriggs@akronzoo.org