### FORM DQT-1. Report on Receipt of Drug - Guide for Reporting Investigational New Animal Drug Shipments for Poikilothermic Food Animals

**[INSTRUCTIONS]{.underline}**

> 1\. Investigator must fill out Form DQT-1
> **[immediately]{.underline}** upon receipt of Reward^7^.
>
> 2\. Investigator should keep the original on file, and send one copy
> to the Study Monitor for review.

3.  Within 10 days of receipt, the Study Monitor should send a copy to
    the AADAP Office.

4.  **[Note:]{.underline}** Both Investigator and Study Monitor should
    sign and date Form DQT-1.

***The sponsor, [U.S. Fish and Wildlife Service]{.underline}, submits a
notice of claimed investigational exemption for the shipment or delivery
of a new animal drug under the provisions of Section 512 of the Federal
Food, Drug, and Cosmetics Act.***

+--------------------------+---------+---------------------+----------+
| Name of Drug             | **Rewa  | INAD Number         | **       |
|                          | rd^7^** |                     | 10-969** |
+--------------------------+---------+---------------------+----------+
| Proposed Use of Drug     | Control |                     |          |
|                          | mo      |                     |          |
|                          | rtality |                     |          |
|                          | caused  |                     |          |
|                          | by      |                     |          |
|                          | ba      |                     |          |
|                          | cterial |                     |          |
|                          | gill    |                     |          |
|                          | disease |                     |          |
|                          | and     |                     |          |
|                          | e       |                     |          |
|                          | xternal |                     |          |
|                          | fl      |                     |          |
|                          | avobact |                     |          |
|                          | eriosis |                     |          |
|                          | in a    |                     |          |
|                          | variety |                     |          |
|                          | of fish |                     |          |
|                          | species |                     |          |
+--------------------------+---------+---------------------+----------+
| Date of CVM              | October |                     |          |
| Authorization Letter     | 31,     |                     |          |
|                          | 2007    |                     |          |
+--------------------------+---------+---------------------+----------+
| **Date of Drug Receipt** |         | **Amount of Drug    |          |
|                          |         | Received**          |          |
+--------------------------+---------+---------------------+----------+
| **Drug Lot Number**      |         | **Study Worksheet   |          |
|                          |         | Number**            |          |
+--------------------------+---------+---------------------+----------+
| **Name of Investigator** |         |                     |          |
+--------------------------+---------+---------------------+----------+
| **Address of             |         |                     |          |
| Investigator**           |         |                     |          |
+--------------------------+---------+---------------------+----------+
| **Location of Trial**    |         |                     |          |
+--------------------------+---------+---------------------+----------+
| Pivotal Study (yes/no)   |         | Non-pivotal Study   |          |
|                          |         | (yes/no)            |          |
+--------------------------+---------+---------------------+----------+
| **Approximate Number of  |         | **Approximate       |          |
| Treated Animals**        |         | Number of Control   |          |
|                          |         | Animals**           |          |
+--------------------------+---------+---------------------+----------+
| **Number of Animals Used |         |                     |          |
| Previously^1^**          |         |                     |          |
+--------------------------+---------+---------------------+----------+
| Study Protocol Number    | 10-969  |                     |          |
+--------------------------+---------+---------------------+----------+
| **Approximate dates of   |         |                     |          |
| trial (start/end)**      |         |                     |          |
+--------------------------+---------+---------------------+----------+
| **Species, Size, and     |         |                     |          |
| Type of Animals**        |         |                     |          |
+--------------------------+---------+---------------------+----------+
| Maximum daily dose and   | 2-18    |                     |          |
| duration                 | mg/L =  |                     |          |
|                          | 4 hr    |                     |          |
|                          |         |                     |          |
|                          | 19-28   |                     |          |
|                          | mg/L =  |                     |          |
|                          | 1 hr    |                     |          |
+--------------------------+---------+---------------------+----------+
| Methods(s) of            | Im      |                     |          |
| Administration           | mersion |                     |          |
|                          | (static |                     |          |
|                          | bath or |                     |          |
|                          | flow-   |                     |          |
|                          | through |                     |          |
|                          | tre     |                     |          |
|                          | atment) |                     |          |
+--------------------------+---------+---------------------+----------+
| Withdrawal Period        | 5 days  |                     |          |
|                          | for     |                     |          |
|                          | channel |                     |          |
|                          | c       |                     |          |
|                          | atfish, |                     |          |
|                          | muske   |                     |          |
|                          | llunge, |                     |          |
|                          | tiger   |                     |          |
|                          | muske   |                     |          |
|                          | llunge, |                     |          |
|                          | and     |                     |          |
|                          | n       |                     |          |
|                          | orthern |                     |          |
|                          | pike;   |                     |          |
|                          | 30 days |                     |          |
|                          | for all |                     |          |
|                          | other   |                     |          |
|                          | fish    |                     |          |
|                          | species |                     |          |
+--------------------------+---------+---------------------+----------+

**^1^ To be filled out by the NIO**

  ------------- ----------------- ------------------- ---------------------------
  **Date                          **Investigator:**   
  Prepared:**                                         

                                                      

  **Date                          **Study Monitor:**  
  Reviewed:**                                         

                                                      

  **Date                          **Sponsor:**        
  Reviewed:**                                         
  ------------- ----------------- ------------------- ---------------------------