<table style="width:100%;">
<colgroup>
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<col style="width: 0%" />
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<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION</strong></td>
<td colspan="16"><strong>REPORT OF TUBERCULIN TESTS OF CATTLE<br />
</strong><em>REQUIRED FOR INTRODUCTION INTO THE UNITED STATES<br />
OF RAW MILK AND CREAM UNDER THE FEDERAL IMPORT MILK ACT</em></td>
<td colspan="3"><p><em><strong>Form Approved; OMB No.
0910-0212</strong></em></p>
<p><em><strong>Expiration Date: December 31, 2008</strong></em></p>
<p><em><strong>See Reverse for OMB Statement</strong></em></p></td>
</tr>
<tr class="even">
<td colspan="9"><p>OWNER</p>
<p>     </p></td>
<td colspan="15"><p>DATE OF EXAMINATION</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="9"><p>ADDRESS</p>
<p>     </p></td>
<td colspan="15"><p>LOCATION OF HERD</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="9"></td>
<td colspan="15"></td>
</tr>
<tr class="odd">
<td rowspan="21"><p>A</p>
<p>N</p>
<p>I</p>
<p>M</p>
<p>A</p>
<p>L</p>
<p>N</p>
<p>O</p>
<p>1</p>
<p>2</p>
<p>3</p>
<p>4</p>
<p>5</p>
<p>6</p>
<p>7</p>
<p>8</p>
<p>9</p>
<p>10</p>
<p>11</p>
<p>12</p>
<p>13</p>
<p>14</p>
<p>15</p>
<p>16</p>
<p>17</p>
<p>18</p></td>
<td rowspan="2"><p>A</p>
<p>G</p>
<p>E</p></td>
<td rowspan="2"><p>S</p>
<p>E</p>
<p>X</p></td>
<td colspan="2" rowspan="2">IDENTIFICATION OF ANIMAL<br />
<em>(Accurate description or ear tag number<br />
or registration name and number)</em></td>
<td colspan="14"><strong>SUBCUTANEOUS</strong></td>
<td colspan="4" rowspan="2"><p>INTRADERMAL<br />
INJECTION</p>
<p>Type <u>     </u></p>
<p>Quantity <u>     </u></p>
<p>Date <u>     </u></p>
<p>Hour <u>     </u></p></td>
<td rowspan="2"><p>CONCLUSIONS<sup>2</sup> <em>(healthy</em></p>
<p><em>reactor,</em></p>
<p><em>suspect)</em></p></td>
</tr>
<tr class="even">
<td colspan="3">*TEMPERATURE<br />
BEFORE INJECTION</td>
<td colspan="2">TIME<br />
OF<br />
INJECTION</td>
<td colspan="2">TUBERCULIN<br />
INJECTION<br />
TYPE/QTY <sup>1</sup></td>
<td colspan="7">TEMPERATURE AFTER<br />
INJECTION</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="2"></td>
<td><u>   </u> M</td>
<td><u>   </u> M</td>
<td><u>   </u> M</td>
<td colspan="2"><u>     </u> M</td>
<td>C.C.</td>
<td>TYPE</td>
<td><u>  </u> M</td>
<td colspan="2"><u>  </u> M</td>
<td><u>  </u> M</td>
<td><u>  </u> M</td>
<td><u>  </u> M</td>
<td><u>   </u> M</td>
<td colspan="4"><strong>OBSERVATIONS</strong></td>
<td rowspan="2">     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td><u>  </u> hrs</td>
<td colspan="2"><u>  </u> hrs</td>
<td><u>  </u> hrs</td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>  </td>
<td></td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="24"><strong>IF MORE SPACE IS NEEDED USE ADDITIONAL FORMS
FDA 1994</strong></td>
</tr>
<tr class="odd">
<td colspan="24"><strong>CERTIFICATION:</strong> I HEREBY CERTIFY THAT I
HAVE INSPECTED AND TESTED WITH TUBERCULIN THE <u>     </u> ANIMALS ABOVE
WITH RESULTS AS STATED.</td>
</tr>
<tr class="even">
<td colspan="4">SIGNATURE OF VETERINARIAN</td>
<td colspan="10"><p>TITLE <em>(Official connection)</em></p>
<p>     </p></td>
<td colspan="10"><p>MAILING ADDRESS <em>(Include ZIP Code)</em></p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="24"><p><em><strong>1. The following symbols may be used to
denote the type of tuberculin: B-Bovine; A-Avian; &amp;
H-Human.</strong></em></p>
<p><em><strong>2. All reactors &amp; suspicious animals must be removed
from herd &amp; certificate of owner to that effect given on the other
side of this form.</strong></em></p></td>
</tr>
</tbody>
</table>

**Public reporting burden for this collection of information is
estimated to average** .25 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing reviewing the collection of
information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for
reducing this burden to:

> DHHS/FDA/DFSAN\
> 5100 Paint Branch Parkway\
> College Park, MD 20740-3835

An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently
valid OMB control number.

**INSTRUCTIONS**

Either the subcutaneous or the intradermal test may be used.

**Subcutaneous Test -**When the subcutaneous tuberculin test is applied
the chart on the other side of this form shall show that at least 3
temperatures were taken, 2 or 3 hours apart, before the injection of
tuberculin; that at least 6 temperatures were taken 2 hours apart,
beginning 8 hours after the injection; and that the test had run for a
period of not less than 18 hours after injection.

**Intradermal Test -**When the intradermal test is applied the chart on
the other side of this form shall show that the last observation was
made not earlier than the seventy-second hour after injection. At least
two observations should be made on animals from infected herds.

**Reactions, Subcutaneous Test -**A rise of 2 degrees Fahrenheit or more
above the maximum temperature observed prior to the injection of
tuberculin or a temperature above 103.8˚ F. should be regarded as an
indication of tuberculosis, provided the temperature reaction shows a
characteristic curve. An elevation of temperature higher than 103.8˚F.

should also be regarded as an indication of tuberculosis, even though
the curve may not be regarded as typical. Animals that after injection
show a rise in temperature of 2 degrees Fahrenheit, with a maximum
between 103˚ and 103.8˚ F., as well as those that show a rise of less
than 2 degrees Fahrenheit, with a maximum temperature of 103.8˚ F., are
regarded as suspicious reactors.

**Reactions, Intradermal Test -**Animals that show at the point of
injection swellings, either hard and circumscribed, or soft and
infiltrated, with no distinct line of demarcation, should be classified
as reactors to the intradermal tuberculin test. Such swellings may be of
various sizes, from those hardly perceptible to the naked eye to those
as large as the human fist or larger. The results of observations on
individual animals should be reported on the test record in accordance
with the prescribed code of the country in which the cattle are tested.
**Identification of Animals -**All animals reported on this chart must
be identified by proper metal ear tags, or registration names and
numbers, or by accurate descriptions.

> I HEREBY CERTIFY that I am the owner of the cows described on the
> other side of this form; that all animals in the herd have been

  -----------------------------------------------------------------------
  tested, and that the animals designated as \"reactors\" and
  \"suspected\" as numbers      

  on this form, have been permanently removed from the herd and disposed
  of as follows .      
  -----------------------------------------------------------------------

> I certify further that no milk or cream from such reactors or
> suspected animals will be introduced into the United States.

  ---------- ------------------------ -- --------------------------- -- -----------
  (Signed)                                                                   

             (Name of Owner)             (Address)                      (Date)
  ---------- ------------------------ -- --------------------------- -- -----------