**Number range CHAPTER Form MT-2. Chemical Use Log for Clinical Field
Trials Using MT Medicated Feed Under**

**INAD #11-236**

**[Instructions:]{.underline}** 1. Investigator should initiate a new
Form MT-2 immediately upon receipt of each shipment of 17alpha
methyltestosterone (MT) medicated feed.

2\. Form MT-2 should be updated whenever MT medicated feed is used,
transferred, or discarded.

3.  Investigator should save all copies of Form MT-2 until the end of
    the calendar year, at which time they should maintain all originals
    on file and send one copy of the completed form(s) to their Study
    Monitor. Within 10 days of receipt, the Study Monitor will ensure
    accuracy and send a copy(s) to the AADAP Office for inclusion in the
    permanent file.

4\. **[Note:]{.underline}** Both Investigator and Study Monitor must
sign and date Form MT-2

**Quantity on Hand Reporting**

**From Previous Page (lbs): \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Facility:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Individual:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 16%" />
<col style="width: 7%" />
<col style="width: 11%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>MT Medicated Feed Batch Number and Manufacture
Date</strong></td>
<td><p><strong>Date</strong></p>
<p><strong>Received</strong></p></td>
<td><strong>Amount Received (kg)</strong></td>
<td><strong>Dates Used</strong></td>
<td><p><strong>Study</strong></p>
<p><strong>Number</strong></p></td>
<td><strong>MT Medicated Feed Used for Teatment (kg)</strong></td>
<td><p><strong>MT Medicated</strong></p>
<p><strong>Feed</strong></p>
<p><strong>Shipped<sup>1</sup> (kg)</strong></p></td>
<td><p><strong>MT Medicated</strong></p>
<p><strong>Feed</strong></p>
<p><strong>Disposal<sup>2</sup> (kg)</strong></p></td>
<td><p><strong>MT Medicated</strong></p>
<p><strong>Feed</strong></p>
<p><strong>On-hand (kg)</strong></p></td>
<td><p><strong>Inventoried by</strong></p>
<p><strong>(initials)</strong></p></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><strong>Shipped</strong></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

^1^ Unused MT medicated feed that is shipped to another facility
participating in MT INAD #11-236 ([Note]{.underline}: MT medicated feed
can only be shipped to another facility with prior

authorization by the AADAP Office).

^2^ Unused MT medicated feed that is disposed of by incineration.

**Investigator: Study Monitor:**

**Signature and Date Signature and Date**

**Form MT-2. Chemical Use Log for Clinical Field Trials Using MT
Medicated Feed Under**

**(Cont.) INAD #11-236**

**Quantity on Hand Reporting**

**From Previous Page (lbs): \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Facility:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Individual:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 16%" />
<col style="width: 7%" />
<col style="width: 11%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>MT Medicated Feed Batch Number and Manufacture
Date</strong></td>
<td><p><strong>Date</strong></p>
<p><strong>Received</strong></p></td>
<td><strong>Amount Received (kg)</strong></td>
<td><strong>Dates Used</strong></td>
<td><p><strong>Study</strong></p>
<p><strong>Number</strong></p></td>
<td><strong>MT Medicated Feed Used for Teatment (kg)</strong></td>
<td><p><strong>MT Medicated</strong></p>
<p><strong>Feed</strong></p>
<p><strong>Shipped<sup>1</sup> (kg)</strong></p></td>
<td><p><strong>MT Medicated</strong></p>
<p><strong>Feed</strong></p>
<p><strong>Disposal<sup>2</sup> (kg)</strong></p></td>
<td><p><strong>MT Medicated</strong></p>
<p><strong>Feed</strong></p>
<p><strong>On-hand (kg)</strong></p></td>
<td><p><strong>Inventoried by</strong></p>
<p><strong>(initials)</strong></p></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td><strong>Shipped</strong></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

^1^ Unused MT medicated feed that is shipped to another facility
participating in MT INAD #11-236 ([Note]{.underline}: MT medicated feed
can only be shipped to another facility with prior

authorization by the AADAP Office).

^2^ Unused MT medicated feed that is disposed of by incineration.

**Investigator: Study Monitor:**

**Signature and Date Signature and Date**