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<tbody>
<tr class="odd">
<td colspan="17">Section</td>
<td colspan="3">9a</td>
</tr>
<tr class="even">
<td colspan="8"><p><strong>FOOD AND DRUG ADMINISTRATION</strong></p>
<p>7500 Standish Place (HFV-210), Room N403</p>
<p>Rockville, MD 20855</p></td>
<td colspan="9"><p><strong>VETERINARY ADVERSE DRUG
REACTION,</strong></p>
<p><strong>LACK OF EFFECTIVENESS,</strong></p>
<p><strong>PRODUCT DEFECT REPORT</strong></p>
<p><em>(Forward to address at left. Attach all correspondence that
pertains to this reaction)</em></p></td>
<td colspan="3"><p><strong>Form Approved: OMB No. 0910-0284</strong></p>
<p id="expiration-date-january-31-2010"
class="heading"><strong>Expiration Date: January 31,
2010</strong></p></td>
</tr>
<tr class="odd">
<td colspan="20"><p>Public reporting burden for this collection of
information is estimated to average 1 hour per response, including the
time for reviewing instructions, searching existing data<br />
sources, gathering and maintaining the data needed, and completing
reviewing the collection of information. Send comments regarding this
burden estimate or any other<br />
aspect of this collection of information, including suggestions for
reducing this burden to:</p>
<p>Food and Drug Administration An agency may not conduct or sponsor,
and a person is not required<br />
7500 Standish Place (HFV-210), Room N403 to respond to, a collection of
information unless it displays a currently<br />
Rockville, MD 20855 valid OMB control number.</p></td>
</tr>
<tr class="even">
<td colspan="20"><em><strong>NOTE: This report is required by law (21
CFR 510.300). Failure to report can result in withdrawal of approval of
the application.</strong></em></td>
</tr>
<tr class="odd">
<td colspan="15" rowspan="5"><p>1. REPORT SOURCE AND ADDRESS <em>(Mfr.,
Distr.)</em></p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="3" rowspan="2"><p>2a. DATE REPORT RECEIVED</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="2">3a. TYPE OF REPORT</td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><p> 3-day Alert 15-day Alert</p>
<p> Periodic Report</p></td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="2"><p>b. DATE SENT TO FDA</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><p>3b. Initial Report</p>
<p> Follow Up Report</p>
<p>Of <em>(Give Date)</em> <u>     </u></p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>c. NUMBER OF DAYS BETWEEN 2a AND b:</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="15"><p>4. NAME, ADDRESS AND PHONE NO. OF ATTENDING
VETERINARIAN</p>
<p><em>(In confidence)</em></p></td>
<td colspan="5" rowspan="5"><p>5. NAME OR CASE IDENTIFICATION OF
OWNER</p>
<p><em>(In confidence)</em></p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="15">Name:      </td>
</tr>
<tr class="even">
<td colspan="15">Street Address:      </td>
</tr>
<tr class="odd">
<td colspan="2">City:</td>
<td colspan="4">     </td>
<td colspan="3">State:</td>
<td colspan="2">  </td>
<td colspan="2">ZIP:</td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="15">Phone No. (     )     -     </td>
</tr>
<tr class="odd">
<td colspan="15"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="15" rowspan="2"><p>6. TRADE NAME AND GENERIC NAME(S) OF
ACTIVE INGREDIENT(S)</p>
<p><em>(Include dosage form and strength - Ex., tab, 500 mg.)</em></p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5"><p>7a. NAME OF MANUFACTURER</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="5"><p>b. NADA NO.</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="3"><p>8. LOT NUMBER(S)</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="12"><p>9. DOSAGE ADMINISTERED AND ROUTE</p>
<p><em>(Ex. 250 mg., q 12 h, p.o.)</em></p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5"><p>10. DATE(S) OF ADMINISTRATION</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="15"><p>11. ILLNESS/REASON FOR USE OF THIS DRUG</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5"><p>12. DRUG WAS ADMINISTERED BY</p>
<p> VETERINARIAN, STAFF OWNER, OTHER</p></td>
</tr>
<tr class="even">
<td colspan="15">13. NUMBER OF ANIMALS IN THIS INCIDENT</td>
<td colspan="5">14. REACTING ANIMALS</td>
</tr>
<tr class="odd">
<td colspan="5"><p>a. TREATED WITH DRUG</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="7"><p>b. REACTED</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="3"><p>c. DIED</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="2"><p>a. SPECIES</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="3"><p>b. BREED</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="15" rowspan="2"><p>15. CONCOMITANT MEDICAL PROBLEMS</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="2"><p>c. AGE</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="3"><p>d. WEIGHT</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="5"><p>e. SEX</p>
<blockquote>
<p> FEMALE MALE PREGNANT NEUTERED</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="14">16. OVERALL STATE OF HEALTH AT TIME OF REACTION</td>
<td colspan="6"><p>17. DID ANY NEW ILLNESS DEVELOP OR DID INITIAL
DIAGNOSIS CHANGE AFTER</p>
<p>SUSPECT DRUG STARTED?</p></td>
</tr>
<tr class="odd">
<td colspan="14"><blockquote>
<p> GOOD FAIR POOR CRITICAL</p>
</blockquote></td>
<td colspan="5"> NO YES <em>(Explain)</em> <u>     </u></td>
<td></td>
</tr>
<tr class="even">
<td colspan="20"><h4 id="concomitant-drugs-administered">18. CONCOMITANT
DRUGS ADMINISTERED</h4></td>
</tr>
<tr class="odd">
<td colspan="7"><h4 id="name-of-drug">NAME OF DRUG</h4></td>
<td colspan="7"><h4 id="route">ROUTE</h4></td>
<td colspan="2"><h4 id="dosage-regimen">DOSAGE REGIMEN</h4></td>
<td colspan="4"><h4 id="dates-of-administration">DATE(S) OF
ADMINISTRATION</h4></td>
</tr>
<tr class="even">
<td colspan="7"><h4 id="section">     </h4></td>
<td colspan="7"><h4 id="section-1">     </h4></td>
<td colspan="2"><h4 id="section-2">     </h4></td>
<td colspan="4"><h4 id="section-3">     </h4></td>
</tr>
<tr class="odd">
<td colspan="7"><h4 id="section-4">     </h4></td>
<td colspan="7"><h4 id="section-5">     </h4></td>
<td colspan="2"><h4 id="section-6">     </h4></td>
<td colspan="4"><h4 id="section-7">     </h4></td>
</tr>
<tr class="even">
<td colspan="7"><h4 id="section-8">     </h4></td>
<td colspan="7"><h4 id="section-9">     </h4></td>
<td colspan="2"><h4 id="section-10">     </h4></td>
<td colspan="4"><h4 id="section-11">     </h4></td>
</tr>
<tr class="odd">
<td colspan="7"><h4 id="section-12">     </h4></td>
<td colspan="7"><h4 id="section-13">     </h4></td>
<td colspan="2"><h4 id="section-14">     </h4></td>
<td colspan="4"><h4 id="section-15">     </h4></td>
</tr>
<tr class="even">
<td colspan="7"><h4 id="section-16">     </h4></td>
<td colspan="7"><h4 id="section-17">     </h4></td>
<td colspan="2"><h4 id="section-18">     </h4></td>
<td colspan="4"><h4 id="section-19">     </h4></td>
</tr>
<tr class="odd">
<td colspan="20"><h4 id="for-fda-use-only">FOR FDA USE ONLY</h4></td>
</tr>
<tr class="even">
<td colspan="10"><h4 id="section-20"></h4></td>
<td colspan="10" rowspan="9"><h1 id="comment">COMMENT</h1>
<p>     </p></td>
</tr>
<tr class="odd">
<td><h1 id="section-21">1.</h1></td>
<td colspan="3"><h1 id="section-22">     </h1></td>
<td colspan="6"><h1 id="d-nai"> D NAI</h1></td>
</tr>
<tr class="even">
<td><h1 id="section-23">2.</h1></td>
<td colspan="3"><h1 id="section-24">     </h1></td>
<td colspan="6"><h1 id="pr-ai"> PR AI</h1></td>
</tr>
<tr class="odd">
<td><h1 id="section-25">3.</h1></td>
<td colspan="3"><h1 id="section-26">     </h1></td>
<td colspan="6"><h1 id="po-ap"> PO AP</h1></td>
</tr>
<tr class="even">
<td><h1 id="section-27">4.</h1></td>
<td colspan="3"><h1 id="section-28">     </h1></td>
<td colspan="6"><h1 id="r-al"> R AL</h1></td>
</tr>
<tr class="odd">
<td><h1 id="section-29">5.</h1></td>
<td colspan="3"><h1 id="section-30">     </h1></td>
<td colspan="6"><h1 id="nc"> NC</h1></td>
</tr>
<tr class="even">
<td><h1 id="section-31">6.</h1></td>
<td colspan="3"><h1 id="section-32">     </h1></td>
<td colspan="6"><h1 id="section-33"></h1></td>
</tr>
<tr class="odd">
<td><h1 id="t.">T.</h1></td>
<td colspan="3"><h1 id="section-34">     </h1></td>
<td colspan="6"><h1 id="section-35"></h1></td>
</tr>
<tr class="even">
<td colspan="10"><h1 id="i.l.-cr-cont"> I.L. CR CONT </h1></td>
</tr>
</tbody>
</table>

+------------+-------------------+---+---+---+-------------+---+-----------------+
| #### REA   |                   |   |   |   |             |   |                 |
| CTION DATA |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 19\.       |                   |   |   |   |             |   |                 |
| DESCRIBE   |                   |   |   |   |             |   |                 |
| SUSPECTED  |                   |   |   |   |             |   |                 |
| ADVERSE    |                   |   |   |   |             |   |                 |
| REACTION:  |                   |   |   |   |             |   |                 |
| INCLUDE    |                   |   |   |   |             |   |                 |
| ALL SIGNS, |                   |   |   |   |             |   |                 |
| RESULTS OF |                   |   |   |   |             |   |                 |
| PERTINENT  |                   |   |   |   |             |   |                 |
| LAB TESTS, |                   |   |   |   |             |   |                 |
| NECROPSY   |                   |   |   |   |             |   |                 |
| RESULTS,   |                   |   |   |   |             |   |                 |
| POSSIBLE   |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
| CO         |                   |   |   |   |             |   |                 |
| NTRIBUTING |                   |   |   |   |             |   |                 |
| FACTORS,   |                   |   |   |   |             |   |                 |
| ETC. ALSO, |                   |   |   |   |             |   |                 |
| INCLUDE IN |                   |   |   |   |             |   |                 |
| THIS       |                   |   |   |   |             |   |                 |
| SECTION    |                   |   |   |   |             |   |                 |
| PRODUCT    |                   |   |   |   |             |   |                 |
| INEFF      |                   |   |   |   |             |   |                 |
| ECTIVENESS |                   |   |   |   |             |   |                 |
| AND        |                   |   |   |   |             |   |                 |
| PRODUCT    |                   |   |   |   |             |   |                 |
| DEFECTS    |                   |   |   |   |             |   |                 |
| SUCH AS    |                   |   |   |   |             |   |                 |
| CRACKED    |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
| TABLETS,   |                   |   |   |   |             |   |                 |
| CLOUDY     |                   |   |   |   |             |   |                 |
| SOLUTION,  |                   |   |   |   |             |   |                 |
| ETC.       |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
| >          |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 20a.       |                   |   |   | 2 |             |   |                 |
| ATTENDING  |                   |   |   | 0 |             |   |                 |
| VETE       |                   |   |   | b |             |   |                 |
| RINARIAN'S |                   |   |   | . |             |   |                 |
| LEVEL OF   |                   |   |   | W |             |   |                 |
| SUSPICION  |                   |   |   | A |             |   |                 |
| THAT DRUG  |                   |   |   | S |             |   |                 |
|            |                   |   |   | T |             |   |                 |
| CAUSED     |                   |   |   | H |             |   |                 |
| REACTION   |                   |   |   | E |             |   |                 |
|            |                   |   |   | R |             |   |                 |
| > HIGH     |                   |   |   | E |             |   |                 |
| > MEDIUM   |                   |   |   | E |             |   |                 |
| > LOW NO   |                   |   |   | X |             |   |                 |
| >          |                   |   |   | T |             |   |                 |
|  ATTENDING |                   |   |   | R |             |   |                 |
| > VET.     |                   |   |   | A |             |   |                 |
|            |                   |   |   | L |             |   |                 |
|            |                   |   |   | A |             |   |                 |
|            |                   |   |   | B |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | L |             |   |                 |
|            |                   |   |   | U |             |   |                 |
|            |                   |   |   | S |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | ( |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | L |             |   |                 |
|            |                   |   |   | U |             |   |                 |
|            |                   |   |   | ) |             |   |                 |
|            |                   |   |   | I |             |   |                 |
|            |                   |   |   | N |             |   |                 |
|            |                   |   |   | V |             |   |                 |
|            |                   |   |   | O |             |   |                 |
|            |                   |   |   | L |             |   |                 |
|            |                   |   |   | V |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | D |             |   |                 |
|            |                   |   |   | ? |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | N |             |   |                 |
|            |                   |   |   | O |             |   |                 |
|            |                   |   |   | Y |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | S |             |   |                 |
|            |                   |   |   | * |             |   |                 |
|            |                   |   |   | ( |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | x |             |   |                 |
|            |                   |   |   | p |             |   |                 |
|            |                   |   |   | l |             |   |                 |
|            |                   |   |   | a |             |   |                 |
|            |                   |   |   | i |             |   |                 |
|            |                   |   |   | n |             |   |                 |
|            |                   |   |   | ) |             |   |                 |
|            |                   |   |   | * |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
|            |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 21\.       |                   |   |   | 2 |             | 2 |                 |
| LENGTH OF  |                   |   |   | 2 |             | 3 |                 |
| TIME       |                   |   |   | \ |             | \ |                 |
| BETWEEN    |                   |   |   | . |             | . |                 |
| LAST       |                   |   |   | D |             | D |                 |
| ADMI       |                   |   |   | A |             | U |                 |
| NISTRATION |                   |   |   | T |             | R |                 |
| OF SUSPECT |                   |   |   | E |             | A |                 |
| DRUG AND   |                   |   |   | O |             | T |                 |
| CAUSED     |                   |   |   | F |             | I |                 |
| REACTION   |                   |   |   | O |             | O |                 |
|            |                   |   |   | N |             | N |                 |
| >          |                   |   |   | S |             | O |                 |
|            |                   |   |   | E |             | F |                 |
|            |                   |   |   | T |             | R |                 |
|            |                   |   |   |   |             | E |                 |
|            |                   |   |   | * |             | A |                 |
|            |                   |   |   | ( |             | C |                 |
|            |                   |   |   | M |             | T |                 |
|            |                   |   |   | o |             | I |                 |
|            |                   |   |   | . |             | O |                 |
|            |                   |   |   | , |             | N |                 |
|            |                   |   |   | d |             |   |                 |
|            |                   |   |   | a |             | * |                 |
|            |                   |   |   | y |             | ( |                 |
|            |                   |   |   | , |             | H |                 |
|            |                   |   |   | y |             | r |                 |
|            |                   |   |   | r |             | s |                 |
|            |                   |   |   | . |             | . |                 |
|            |                   |   |   | ) |             | , |                 |
|            |                   |   |   | * |             | d |                 |
|            |                   |   |   |   |             | a |                 |
|            |                   |   |   | > |             | y |                 |
|            |                   |   |   |   |             | s |                 |
|            |                   |   |   |   |             | , |                 |
|            |                   |   |   |   |             | e |                 |
|            |                   |   |   |   |             | t |                 |
|            |                   |   |   |   |             | c |                 |
|            |                   |   |   |   |             | . |                 |
|            |                   |   |   |   |             | ) |                 |
|            |                   |   |   |   |             | * |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             | > |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 24\. WAS   |                   |   |   | 2 |             |   |                 |
| THE        |                   |   |   | 5 |             |   |                 |
| ADVERSE    |                   |   |   | \ |             |   |                 |
| REACTION   |                   |   |   | . |             |   |                 |
| TREATED?   |                   |   |   | O |             |   |                 |
|            |                   |   |   | U |             |   |                 |
| > NO YES   |                   |   |   | T |             |   |                 |
| >          |                   |   |   | C |             |   |                 |
| *(Describe |                   |   |   | O |             |   |                 |
| > t        |                   |   |   | M |             |   |                 |
| reatment)* |                   |   |   | E |             |   |                 |
| >          |                   |   |   | O |             |   |                 |
| >          |                   |   |   | F |             |   |                 |
|            |                   |   |   | R |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | A |             |   |                 |
|            |                   |   |   | C |             |   |                 |
|            |                   |   |   | T |             |   |                 |
|            |                   |   |   | I |             |   |                 |
|            |                   |   |   | O |             |   |                 |
|            |                   |   |   | N |             |   |                 |
|            |                   |   |   | T |             |   |                 |
|            |                   |   |   | O |             |   |                 |
|            |                   |   |   | D |             |   |                 |
|            |                   |   |   | A |             |   |                 |
|            |                   |   |   | T |             |   |                 |
|            |                   |   |   | E |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | D |             |   |                 |
|            |                   |   |   | I |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | D |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | * |             |   |                 |
|            |                   |   |   | ( |             |   |                 |
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|            |                   |   |   | i |             |   |                 |
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|            |                   |   |   | e |             |   |                 |
|            |                   |   |   | ) |             |   |                 |
|            |                   |   |   | * |             |   |                 |
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|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | [ |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | ] |             |   |                 |
|            |                   |   |   | { |             |   |                 |
|            |                   |   |   | . |             |   |                 |
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|            |                   |   |   | R |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | M |             |   |                 |
|            |                   |   |   | A |             |   |                 |
|            |                   |   |   | I |             |   |                 |
|            |                   |   |   | N |             |   |                 |
|            |                   |   |   | S |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | U |             |   |                 |
|            |                   |   |   | N |             |   |                 |
|            |                   |   |   | D |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | R |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | T |             |   |                 |
|            |                   |   |   | R |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | A |             |   |                 |
|            |                   |   |   | T |             |   |                 |
|            |                   |   |   | M |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | N |             |   |                 |
|            |                   |   |   | T |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | A |             |   |                 |
|            |                   |   |   | L |             |   |                 |
|            |                   |   |   | I |             |   |                 |
|            |                   |   |   | V |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | W |             |   |                 |
|            |                   |   |   | I |             |   |                 |
|            |                   |   |   | T |             |   |                 |
|            |                   |   |   | H |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | S |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | Q |             |   |                 |
|            |                   |   |   | U |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | L |             |   |                 |
|            |                   |   |   | A |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | R |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | C |             |   |                 |
|            |                   |   |   | O |             |   |                 |
|            |                   |   |   | V |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | R |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | D |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   | > |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   |   |   | U |             |   |                 |
|            |                   |   |   | N |             |   |                 |
|            |                   |   |   | K |             |   |                 |
|            |                   |   |   | N |             |   |                 |
|            |                   |   |   | O |             |   |                 |
|            |                   |   |   | W |             |   |                 |
|            |                   |   |   | N |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 26\. WHEN  |                   |   |   |   |             |   |                 |
| REACTION   |                   |   |   |   |             |   |                 |
| APPEARED,  |                   |   |   |   |             |   |                 |
| TREATMENT  |                   |   |   |   |             |   |                 |
| WITH       |                   |   |   |   |             |   |                 |
| SUSPECT    |                   |   |   |   |             |   |                 |
| DRUG:      |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| > HAD      |                   |   |   | > |             |   |                 |
| > ALREADY  |                   |   |   | > |             |   |                 |
| > BEEN     |                   |   |   |   |             |   |                 |
| >          |                   |   |   | C |             |   |                 |
|  COMPLETED |                   |   |   | O |             |   |                 |
| >          |                   |   |   | N |             |   |                 |
| > DI       |                   |   |   | T |             |   |                 |
| SCONTINUED |                   |   |   | I |             |   |                 |
| > DUE TO   |                   |   |   | N |             |   |                 |
| > THE      |                   |   |   | U |             |   |                 |
| > REACTION |                   |   |   | E |             |   |                 |
| >          |                   |   |   | D |             |   |                 |
| > DIS      |                   |   |   | > |             |   |                 |
| CONTINUED, |                   |   |   | > |             |   |                 |
| > REPLACE  |                   |   |   |   |             |   |                 |
| > WITH     |                   |   |   | S |             |   |                 |
| > ANOTHER  |                   |   |   | T |             |   |                 |
| > DRUG     |                   |   |   | O |             |   |                 |
| >          |                   |   |   | P |             |   |                 |
| > DIS      |                   |   |   | P |             |   |                 |
| CONTINUED, |                   |   |   | E |             |   |                 |
| > RE       |                   |   |   | D |             |   |                 |
| INTRODUCED |                   |   |   | > |             |   |                 |
| > LATER    |                   |   |   | > |             |   |                 |
| >          |                   |   |   |   |             |   |                 |
| >          |                   |   |   | R |             |   |                 |
|  CONTINUED |                   |   |   | E |             |   |                 |
| > AT       |                   |   |   | C |             |   |                 |
| > ALTERED  |                   |   |   | U |             |   |                 |
| > DOSE     |                   |   |   | R |             |   |                 |
|            |                   |   |   | R |             |   |                 |
|            |                   |   |   | E |             |   |                 |
|            |                   |   |   | D |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| > OTHER    |                   |   |   |   | > OTHER     |   |                 |
| > *        |                   |   |   |   | >           |   |                 |
| (Explain)* |                   |   |   |   | *(Explain)* |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
|            |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 27\. HAD   |                   |   |   |   |             |   |                 |
| ANIMAL(S)  |                   |   |   |   |             |   |                 |
| BEEN       |                   |   |   |   |             |   |                 |
| PREVIOUSLY |                   |   |   |   |             |   |                 |
| EXPOSED TO |                   |   |   |   |             |   |                 |
| THIS DRUG? |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| NO YES     |                   |   |   |   |             |   |                 |
| UNKNOWN    |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 28\. DID   |                   |   |   |   |             |   |                 |
| ANIMAL(S)  |                   |   |   |   |             |   |                 |
| PREVIOUSLY |                   |   |   |   |             |   |                 |
| REACT TO   |                   |   |   |   |             |   |                 |
| THIS DRUG? |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| NO YES     |                   |   |   |   |             |   |                 |
| UNKNOWN    |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 29\. HAD   |                   |   |   |   |             |   |                 |
| ANIMAL(S)  |                   |   |   |   |             |   |                 |
| PREVIOUSLY |                   |   |   |   |             |   |                 |
| REACTED TO |                   |   |   |   |             |   |                 |
| OTHER      |                   |   |   |   |             |   |                 |
| DRUGS?     |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| NO YES     |                   |   |   |   |             |   |                 |
| UNKNOWN    |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
| *(If yes,  |                   |   |   |   |             |   |                 |
| give       |                   |   |   |   |             |   |                 |
| drug(s)    |                   |   |   |   |             |   |                 |
| and        |                   |   |   |   |             |   |                 |
| reaction   |                   |   |   |   |             |   |                 |
| if known)* |                   |   |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
| >          |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 30\. HAS   |                   |   |   |   |             |   |                 |
| THE        |                   |   |   |   |             |   |                 |
| ATTENDING  |                   |   |   |   |             |   |                 |
| VE         |                   |   |   |   |             |   |                 |
| TERINARIAN |                   |   |   |   |             |   |                 |
| SEEN       |                   |   |   |   |             |   |                 |
| SIMILAR    |                   |   |   |   |             |   |                 |
| REACTIONS  |                   |   |   |   |             |   |                 |
| TO THIS    |                   |   |   |   |             |   |                 |
| DRUG IN    |                   |   |   |   |             |   |                 |
| ANY OTHER  |                   |   |   |   |             |   |                 |
| ANIMALS?   |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| NO YES     |                   |   |   |   |             |   |                 |
| *(Describe |                   |   |   |   |             |   |                 |
| t          |                   |   |   |   |             |   |                 |
| reatment)* |                   |   |   |   |             |   |                 |
| [     ]{.  |                   |   |   |   |             |   |                 |
| underline} |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| 31\. NAME  |                   | 3 |   |   |             |   |                 |
| AND TITLE  |                   | 2 |   |   |             |   |                 |
| OF         |                   | \ |   |   |             |   |                 |
| INDIVIDUAL |                   | . |   |   |             |   |                 |
| R          |                   | S |   |   |             |   |                 |
| ESPONSIBLE |                   | I |   |   |             |   |                 |
| FOR        |                   | G |   |   |             |   |                 |
| ACCURACY   |                   | N |   |   |             |   |                 |
|            |                   | A |   |   |             |   |                 |
| OF         |                   | T |   |   |             |   |                 |
| REPORTED   |                   | U |   |   |             |   |                 |
| I          |                   | R |   |   |             |   |                 |
| NFORMATION |                   | E |   |   |             |   |                 |
| *(Type or  |                   | O |   |   |             |   |                 |
| print)*    |                   | F |   |   |             |   |                 |
|            |                   | I |   |   |             |   |                 |
|            |                   | N |   |   |             |   |                 |
|            |                   | D |   |   |             |   |                 |
|            |                   | I |   |   |             |   |                 |
|            |                   | V |   |   |             |   |                 |
|            |                   | I |   |   |             |   |                 |
|            |                   | D |   |   |             |   |                 |
|            |                   | U |   |   |             |   |                 |
|            |                   | A |   |   |             |   |                 |
|            |                   | L |   |   |             |   |                 |
|            |                   | R |   |   |             |   |                 |
|            |                   | E |   |   |             |   |                 |
|            |                   | S |   |   |             |   |                 |
|            |                   | P |   |   |             |   |                 |
|            |                   | O |   |   |             |   |                 |
|            |                   | N |   |   |             |   |                 |
|            |                   | S |   |   |             |   |                 |
|            |                   | I |   |   |             |   |                 |
|            |                   | B |   |   |             |   |                 |
|            |                   | L |   |   |             |   |                 |
|            |                   | E |   |   |             |   |                 |
|            |                   | F |   |   |             |   |                 |
|            |                   | O |   |   |             |   |                 |
|            |                   | R |   |   |             |   |                 |
|            |                   | A |   |   |             |   |                 |
|            |                   | C |   |   |             |   |                 |
|            |                   | C |   |   |             |   |                 |
|            |                   | U |   |   |             |   |                 |
|            |                   | R |   |   |             |   |                 |
|            |                   | A |   |   |             |   |                 |
|            |                   | C |   |   |             |   |                 |
|            |                   | Y |   |   |             |   |                 |
|            |                   | O |   |   |             |   |                 |
|            |                   | F |   |   |             |   |                 |
|            |                   | R |   |   |             |   |                 |
|            |                   | E |   |   |             |   |                 |
|            |                   | P |   |   |             |   |                 |
|            |                   | O |   |   |             |   |                 |
|            |                   | R |   |   |             |   |                 |
|            |                   | T |   |   |             |   |                 |
|            |                   | E |   |   |             |   |                 |
|            |                   | D |   |   |             |   |                 |
|            |                   |   |   |   |             |   |                 |
|            |                   | I |   |   |             |   |                 |
|            |                   | N |   |   |             |   |                 |
|            |                   | F |   |   |             |   |                 |
|            |                   | O |   |   |             |   |                 |
|            |                   | R |   |   |             |   |                 |
|            |                   | M |   |   |             |   |                 |
|            |                   | A |   |   |             |   |                 |
|            |                   | T |   |   |             |   |                 |
|            |                   | I |   |   |             |   |                 |
|            |                   | O |   |   |             |   |                 |
|            |                   | N |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+
| >          |                   |   |   |   |             |   |                 |
+------------+-------------------+---+---+---+-------------+---+-----------------+