Equine Grass Sickness Surveillance

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Confidential Premises Questionnaire

Please fill in this form once to provide details of your premises history
Please complete the 'Case report questionnaire' if you wish to report new cases of EGS.

PLEASE READ THESE NOTES BEFORE COMPLETING THE QUESTIONNAIRE:

1. This form is for one premises only. It only needs to be filled in once. Please complete the 'Case report questionnaire' if you wish to report new cases of EGS.
2. Please answer all the relevant questions and complete both sections of this questionnaire. It will help us with our records to receive all questionnaires back, even if you had no cases of EGS since the year 2000.
3. Please write in BLOCK CAPITALS in the spaces provided.
4. Please tick the appropriate box as directed.
5. For more information of clarification on any aspect of this study please contact Georgette Kluiters: Telephone 01638 555664 Ext: 1203 E-mail: georgette.kluiters@aht.org.uk

Section 1: PREMISES HISTORY OF EQUINE GRASS SICKNESS (EGS)

This section contains questions regarding one premises affected by cases of equine grass sickness. If you have had cases of EGS at a different location please fill in a separate form for that premises.

1. Where were the affected horses grazing when they developed clinical signs of EGS?

Address:

Town:

Region/County:

Postcode:

2. Since what date are you aware of the history of the premises? (DD/MM/YYYY)

3. How many cases of EGS are you aware have occured on the affected premises since the year 2000?

4. For each of these cases (since the year 2000), please provide details of the affected horses:

Case	Date of onset of EGS clinical signs	Name of horse	Age (years)	Sex (Mare/Gelding /Stallion)	Breed
Example Case	29/05/2005	HAMISH	5	GELDING	SHETLAND
Most Recent Case
Previous Case 1
Previous Case 2
Previous Case 3
Previous Case 4
Previous Case 5
Previous Case 6
Previous Case 7

5. For each case please tick which box best describes the clinical signs (please tick one option per horse only):

Name of Horse	Clinical Signs
	Acute Grass Sickness (Colic: died/put down within 48 hours)		Subacute Grass Sickness (Colic: died/put down withn 2-7 days)		Chronic Grass Sickness (Weight loss: survived longer than 7 days)			Other: please describe
	Put down by vet	Died Naturally	Put down by vet	Died Naturally	Put down by vet	Died Naturally	Survived
Example HAMISH
Recent Case
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7

6. For each case please tick which boxes best describe how the diagnosis was made (Please tick all boxes that aply):

Name of Horse	Diagnostic Techniques
	Clinical Signs		Surgery		Post-Mortem Examination		Other: please describe
	By a veterinary surgeon	By owner/ keeper/ other non- veterinary personnel	With gut biopsy (histop-athology)	Without gut biopsy (histopa-thology)	With ganglia exami-nation	Without ganglia exam-ination
Example HAMISH
Recent Case
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7

7. For each case please provide details for the premises and affected paddock:

Name of Horse	Whole Premises				Affected Paddock Only
	Length of time horse was on premises prior to becoming ill	Area of grazing available for horses		Total number of horses on premises	Length of time horse was grazing prior to becoming ill	Area of grazing available for horses		Total number of horses in paddock
	Length of time horse was on premises prior to becoming ill	Acres	Hectares	Total number of horses on premises	Length of time horse was grazing prior to becoming ill	Acres	Hectares	Total number of horses in paddock
Example HAMISH	4 Years	24	N/A	14	2 weeks	6	N/A	3
Recent Case
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7

Section 2: YOUR CONTACT DETAILS

This section contains questions about you and will remain confidential. We are proposing to follow up this study with a short questionnaire. Please indicate your preferred methods of communication, which are optional, by ticking the appropriate 'Contact Preference' boxes.

8. Title: Miss / Mr / Mrs / Dr / other:

First Name: Surname:

9. Is your contact address the same as the address given for the horse in section 1?

Yes > If 'Yes' please go to question 10.

No > If 'No' please complete the following.

Address:

Town: Region/County:

Postcode:

10. Telephone Number:

11. Fax Number:

12. E-mail address:

13. What is your preferred method of contact? Mail Phone Fax E-mail

Please enter the date of completion of this questionnaire:

dd/mm/yyyy

Thank you for filling in this questionnaire. Please look below for contact details at the AHT.

This space is for you to make any additional comments that you may have on the questionnaire, this study or specific issues you feel are important. Please use this space to give us any more information that you think may be useful about your experience of EGS. Your input is welcomed:

This is a confidential study and we will not pass on any information to any other party without your permission. However, if you would like your details to be submitted to the Equine Grass Sickness Fund – the only charity dedicated to supporting and advancing research into grass sickness and further improving the treatment of chronic cases - then please tick here The Equine Grass Sickness Fund will then also be aware of your case and may contact you with more information about the disease.

Thank you for filling in this questionnaire.

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