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  **Number range              **Page 1 of 2**
  CHAPTERSTUDY                
  NUMBER**                    

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**Form MT-3: Results Report Form for Clinical Field Trials Using MT
Medicated Feed Under INAD 11-236**

**[INSTRUCTIONS]{.underline}**

1\. Investigator must fill out Form MT-3 no later than 10 days after
completion of treatment. Study Number must be recorded on all pages of
Form MT-3. Attach lab reports and other information.

2\. If MT was not used under the assigned Study Number, fill out only
the Site Information portion on this page, and skip to the end of page 2
and fill out only the \"Negative Report\" section.

3\. Investigator should keep the original on file, and send a copy to
the Study Monitor. Within 10 days of receipt, the Study Monitor should
send a copy to the AADAP Office for inclusion in the permanent file.

4.  **[Note:]{.underline}** Both Investigator and Study Monitor should
    sign and date Form MT-3.

**SITE INFORMATION**

  --------------- -------------------------------------------------------
  Facility        

  Reporting       
  Individual      
  --------------- -------------------------------------------------------

**FISH CULTURE AND DRUG TREATMENT INFORMATION**

  -------------------- ------------- ------------------------ ------------
  MT medicated feed                  MT medicated feed        
  batch number                       manufacture date         

  Treatment dosage     **9 mg/kg     Treatment duration       **28 days**
                       bw/day**                               

  Fish species treated               Total number of fish     
                                     treated                  

  Number of rearing                  Number of fish per       
  units treated                      treated rearing unit     

  ID of all treated                                           
  rearing units (e.g.                                         
  Tank 5, Pond 6B)                                            

  Number of control                  Number of fish per       
  units                              control unit             

  Fish age (days                     Average fish length (mm) 
  post-hatch)                                                 

  Treatment date                     Treatment date           
  (initiated)                        (completed)              

  Sample collection1                 Sample collection date   
  (yes/no)                                                    

  Number of fish                                              
  remaining at the                                            
  completion of the                                           
  treatment period                                            
  (i.e. number of fish                                        
  treated minus                                               
  treatment period                                            
  mortality)                                                  
  -------------------- ------------- ------------------------ ------------

^1^ Sample of 60 fish collected for determination of sex ratio and sent
to AADAP Office for histological evaluation

**WATER QUALITY PARAMETERS**

+----------------------+-----------+------------------+---------------+
| Mean Treatment       |           | Mean Dissolved   |               |
| Temperature          |           | Oxygen           |               |
|                      |           |                  |               |
| (^o^F)               |           | (mg/L)           |               |
+----------------------+-----------+------------------+---------------+
| Mean pH              |           | Mean Hardness -  |               |
|                      |           | CaCO3            |               |
|                      |           |                  |               |
|                      |           | (mg/L)           |               |
+----------------------+-----------+------------------+---------------+

**RESULTS:** Describe in brief detail treatment results. Did treatment
go as planned? Did all fish readily consume MT medicated feed? Was any
unusual fish behavior or unexpected mortality associated with the
treatment?? If treatment did not appear to be successful, explain why
not? Were there any mitigating environmental conditions that may have
impacted treatment results? Were there any deviations from the Study
Protocol?

**Toxicity observations:** Report any apparent drug toxicity including a
description of unusual fish behavior.

**OBSERVED WITHDRAWAL PERIOD OF TREATED FISH:**

  ------------------------------ ------- ---------------------------------
  **Observed withdrawal period           **120 days** (Investigator should
  for BATCH CULTURE:**                   initial)

  ------------------------------ ------- ---------------------------------

  -------------------------- ------ -------------------------------------
  **Observed withdrawal             **350 g fish weight** (Investigator
  period for PARTIAL                should initial)
  HARVEST/RESTOCK CULTURE:**        

  -------------------------- ------ -------------------------------------

  ------------------------------------------------------- ---------------
  Estimated number of days between last treatment and     
  first availability of fish for human consumption        
  (ensure this time period meets the withdrawal period).  

                                                          
  ------------------------------------------------------- ---------------

DISPOSITION OF MT MEDICATED FEED

  ----- -----------------------------------------------------------------
        Use and disposition of all MT medicated feed followed Study
        Protocol guidelines and has been clearly identified on Form MT-2
        (Investigator should initial)

  ----- -----------------------------------------------------------------

> **NEGATIVE REPORT** MT medicated feed was not used at this facility
> under this Study Number during the reporting period. (Investigator
> should initial for negative reports as soon as the Study Number is
> known to be no longer needed or valid.)

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

                                                      

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