<table>
<colgroup>
<col style="width: 21%" />
<col style="width: 2%" />
<col style="width: 23%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 13%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12">Section       1932A</td>
</tr>
<tr class="even">
<td colspan="12"><strong>FOLD, SEAL, AND RETURN</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><p><strong>VETERINARY ADVERSE DRUG REACTION, LACK
OF</strong></p>
<p><strong>EFFECTIVENESS OR PRODUCT DEFECT REPORT</strong></p></td>
<td colspan="3"><p>DATE REPORTED</p>
<p>     </p></td>
<td colspan="5"><p>Form Approved: OMB No. 0910-0284</p>
<p id="expiration-date-june-30-2006" class="heading">Expiration Date:
June 30, 2006</p></td>
</tr>
<tr class="even">
<td colspan="12"><em><strong>NOTE: This report is authorized by 21 U.S.C
352(a) and (f). While you are not required to report, your cooperation
is needed to<br />
assure comprehensive and timely assessment of product
labeling.</strong></em></td>
</tr>
<tr class="odd">
<td rowspan="5"><p id="if-you-do-not-want" class="heading">If you do NOT
want</p>
<blockquote>
<p><strong>your identity disclosed</strong></p>
<p><strong>to the manufacturer,</strong></p>
<p><strong>place an "X" in this</strong></p>
<p><strong>box.</strong> </p>
</blockquote></td>
<td colspan="6">1. VETERINARIAN’S NAME AND ADDRESS</td>
<td colspan="5">2. OWNER’S NAME OR CASE ID</td>
</tr>
<tr class="even">
<td colspan="6" rowspan="2"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5"><em>(In Confidence)</em></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="6" rowspan="2"><blockquote>
<p>TELEPHONE (Include Area Code)     -     -     </p>
</blockquote></td>
<td colspan="5">3. NADA NUMBER (For FDA Use)</td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="7">4. SUSPECTED DRUG AND DOSAGE FORM</td>
<td colspan="5">5. MANUFACTURER’S NAME</td>
</tr>
<tr class="odd">
<td colspan="7"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="7">6. DIAGNOSIS AND / OR REASON FOR USE OF DRUG</td>
<td colspan="5">7. ADMINISTERED BY</td>
</tr>
<tr class="odd">
<td colspan="7"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5"><p> VETERINARIAN</p>
<p> OWNER</p></td>
</tr>
<tr class="even">
<td colspan="7">8. DOSAGE ADMINISTERED AND ROUTE <em>(Ex. 250 mg. q 12h,
5 days, orally)</em></td>
<td colspan="5">9. DATE(S) OF ADMINISTRATION</td>
</tr>
<tr class="odd">
<td colspan="7"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="2">10. SPECIES</td>
<td>11. BREED</td>
<td colspan="4">12. AGE</td>
<td>13. SEX</td>
<td colspan="4">14. WEIGHT</td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="2"><blockquote>
<p>     </p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="4" rowspan="2"><blockquote>
<p>   </p>
</blockquote></td>
<td><blockquote>
&#10;</blockquote></td>
<td></td>
<td>    </td>
<td colspan="2">LBS.</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3">15. CONCURRENT CLINICAL PROBLEMS</td>
<td colspan="9">16. CONCURRENT DRUGS ADMINISTERED</td>
</tr>
<tr class="even">
<td colspan="3"><blockquote>
<p> NONE</p>
<p>     </p>
</blockquote></td>
<td colspan="9" rowspan="2"><blockquote>
<p> NONE</p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"><blockquote>
<p>OVERALL STATE OF HEALTH WHEN SUSPECTED DRUG GIVEN:</p>
<p> GOOD FAIR POOR CRITICAL</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="12"><strong>17. REACTION INFORMATION</strong></td>
</tr>
<tr class="odd">
<td colspan="6">a. TIME BETWEEN INITIATION OF THERAPY WITH SUSPECTED
DRUG AND ONSET OF REACTION WAS</td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="5">b. TIME BETWEEN LAST ADMINISTRATION OF SUSPECTED DRUG
AND ONSET OF REACTION WAS</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"><p>c. OUTCOME: RECOVERED FROM REACTION DIED FROM
REACTION OTHER <em>(Comment Below)</em></p>
<p>d. WAS THE REACTION TREATED? NO YES <em>(Comment Below)</em></p>
<p>e. WHEN THE REACTION APPEARED, TREATMENT WITH SUSPECTED DRUG:</p>
<p> HAD ALREADY BEEN COMPLETED</p>
<p> WAS DISCONTINUED DUE TO REACTION CONTINUED</p>
<p> WAS DISCONTINUED AND REPLACED WITH ANOTHER DRUG <strong>AND
THE</strong> STOPPED</p>
<p> WAS DISCONTINUED AND REINTRODUCED LATER <strong>REACTION</strong>
RECURRED</p>
<p> WAS CONTINUED AT ALTERED DOSE OTHER <em>(Comment Below)</em></p>
<p> OTHER <em>(Comment Below)</em></p>
<p>f. LEVEL OF SUSPICION THAT DRUG CAUSED THE REACTION: HIGH MEDIUM
LOW</p></td>
</tr>
<tr class="even">
<td colspan="12"><p>18. DESCRIBE THE REACTION, ADD DETAILS ABOUT CASE
HISTORY AND OUTCOME <em>(Include numbers if group of animals
involved)</em> , GIVE COMMENT ON</p>
<p>POSSIBLE CONTRIBUTING FACTORS. DESCRIBE LACK OF EFFECTIVENESS OR
PRODUCT DEFECT <em>(Include Expiration Date and Lot No.)</em></p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="12"><em>NOTE: Triple fold as marked, seal with tape, no
postage required, additional space on back, if needed.</em></td>
</tr>
</tbody>
</table>

+---+--------+-----------+-------------------+--------------------------+
| ! |        |           |                   |                          |
| [ |        |           |                   |                          |
| ] |        |           |                   |                          |
| ( |        |           |                   |                          |
| m |        |           |                   |                          |
| e |        |           |                   |                          |
| d |        |           |                   |                          |
| i |        |           |                   |                          |
| a |        |           |                   |                          |
| / |        |           |                   |                          |
| i |        |           |                   |                          |
| m |        |           |                   |                          |
| a |        |           |                   |                          |
| g |        |           |                   |                          |
| e |        |           |                   |                          |
| 1 |        |           |                   |                          |
| . |        |           |                   |                          |
| j |        |           |                   |                          |
| p |        |           |                   |                          |
| e |        |           |                   |                          |
| g |        |           |                   |                          |
| ) |        |           |                   |                          |
| { |        |           |                   |                          |
| w |        |           |                   |                          |
| i |        |           |                   |                          |
| d |        |           |                   |                          |
| t |        |           |                   |                          |
| h |        |           |                   |                          |
| = |        |           |                   |                          |
| " |        |           |                   |                          |
| 0 |        |           |                   |                          |
| . |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 2 |        |           |                   |                          |
| 2 |        |           |                   |                          |
| 9 |        |           |                   |                          |
| 1 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 6 |        |           |                   |                          |
| 7 |        |           |                   |                          |
| i |        |           |                   |                          |
| n |        |           |                   |                          |
| " |        |           |                   |                          |
| h |        |           |                   |                          |
| e |        |           |                   |                          |
| i |        |           |                   |                          |
| g |        |           |                   |                          |
| h |        |           |                   |                          |
| t |        |           |                   |                          |
| = |        |           |                   |                          |
| " |        |           |                   |                          |
| 0 |        |           |                   |                          |
| . |        |           |                   |                          |
| 7 |        |           |                   |                          |
| 0 |        |           |                   |                          |
| 1 |        |           |                   |                          |
| 3 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| i |        |           |                   |                          |
| n |        |           |                   |                          |
| " |        |           |                   |                          |
| } |        |           |                   |                          |
|   |        |           |                   |                          |
| T |        |           |                   |                          |
| H |        |           |                   |                          |
| A |        |           |                   |                          |
| N |        |           |                   |                          |
| K |        |           |                   |                          |
| Y |        |           |                   |                          |
| O |        |           |                   |                          |
| U |        |           |                   |                          |
| F |        |           |                   |                          |
| O |        |           |                   |                          |
| R |        |           |                   |                          |
| S |        |           |                   |                          |
| H |        |           |                   |                          |
| A |        |           |                   |                          |
| R |        |           |                   |                          |
| I |        |           |                   |                          |
| N |        |           |                   |                          |
| G |        |           |                   |                          |
| Y |        |           |                   |                          |
| O |        |           |                   |                          |
| U |        |           |                   |                          |
| R |        |           |                   |                          |
| C |        |           |                   |                          |
| O |        |           |                   |                          |
| N |        |           |                   |                          |
| C |        |           |                   |                          |
| E |        |           |                   |                          |
| R |        |           |                   |                          |
| N |        |           |                   |                          |
| A |        |           |                   |                          |
| B |        |           |                   |                          |
| O |        |           |                   |                          |
| U |        |           |                   |                          |
| T |        |           |                   |                          |
| A |        |           |                   |                          |
| N |        |           |                   |                          |
| I |        |           |                   |                          |
| M |        |           |                   |                          |
| A |        |           |                   |                          |
| L |        |           |                   |                          |
| D |        |           |                   |                          |
| R |        |           |                   |                          |
| U |        |           |                   |                          |
| G |        |           |                   |                          |
| E |        |           |                   |                          |
| F |        |           |                   |                          |
| F |        |           |                   |                          |
| E |        |           |                   |                          |
| C |        |           |                   |                          |
| T |        |           |                   |                          |
| S |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| 1 |        |           |                   |                          |
| 8 |        |           |                   |                          |
| \ |        |           |                   |                          |
| . |        |           |                   |                          |
| * |        |           |                   |                          |
| ( |        |           |                   |                          |
| C |        |           |                   |                          |
| o |        |           |                   |                          |
| n |        |           |                   |                          |
| t |        |           |                   |                          |
| i |        |           |                   |                          |
| n |        |           |                   |                          |
| u |        |           |                   |                          |
| e |        |           |                   |                          |
| d |        |           |                   |                          |
| ) |        |           |                   |                          |
| * |        |           |                   |                          |
|   |        |           |                   |                          |
|   |        |           |                   |                          |
|   |        |           |                   |                          |
|   |        |           |                   |                          |
|   |        |           |                   |                          |
|   |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        |           |                   |                          |
|   |        |           |                   |                          |
| F |        |           |                   |                          |
| O |        |           |                   |                          |
| R |        |           |                   |                          |
|   |        |           |                   |                          |
| F |        |           |                   |                          |
| D |        |           |                   |                          |
| A |        |           |                   |                          |
|   |        |           |                   |                          |
| U |        |           |                   |                          |
| S |        |           |                   |                          |
| E |        |           |                   |                          |
|   |        |           |                   |                          |
| O |        |           |                   |                          |
| N |        |           |                   |                          |
| L |        |           |                   |                          |
| Y |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        | #  D  NAI | # Confid          | # COMMENT                |
|   |        |           | entiality: The ow |                          |
| 1 |        |           | ner's identity is |                          |
| . |        |           |                   |                          |
|   |        |           | held in strict    |                          |
|   |        |           | confidence by FDA |                          |
|   |        |           | and               |                          |
|   |        |           |                   |                          |
|   |        |           | protected to the  |                          |
|   |        |           | fullest extent of |                          |
|   |        |           | the law.          |                          |
|   |        |           |                   |                          |
|   |        |           | The reporter's    |                          |
|   |        |           | identity,         |                          |
|   |        |           | including the     |                          |
|   |        |           |                   |                          |
|   |        |           | identity of       |                          |
|   |        |           | self-reporter,    |                          |
|   |        |           | may be shared     |                          |
|   |        |           |                   |                          |
|   |        |           | with the          |                          |
|   |        |           | manufacturer      |                          |
|   |        |           | unless requested  |                          |
|   |        |           |                   |                          |
|   |        |           | otherwise.        |                          |
|   |        |           | However, FDA will |                          |
|   |        |           | not               |                          |
|   |        |           |                   |                          |
|   |        |           | disclose the      |                          |
|   |        |           | reporter's        |                          |
|   |        |           | identity in       |                          |
|   |        |           | response          |                          |
|   |        |           |                   |                          |
|   |        |           | to a request from |                          |
|   |        |           | the public,       |                          |
|   |        |           | pursuant to       |                          |
|   |        |           |                   |                          |
|   |        |           | the Freedom of    |                          |
|   |        |           | Information Act.  |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        | #  PR  AI |                   |                          |
|   |        |           |                   |                          |
| 2 |        |           |                   |                          |
| . |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        | #  PO  AP |                   |                          |
|   |        |           |                   |                          |
| 3 |        |           |                   |                          |
| . |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        | #  R  AL  |                   |                          |
|   |        |           |                   |                          |
| 4 |        |           |                   |                          |
| . |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        | #  NC     |                   |                          |
|   |        |           |                   |                          |
| 5 |        |           |                   |                          |
| . |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        | #         |                   |                          |
|   |        |           |                   |                          |
| 6 |        |           |                   |                          |
| . |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        | #         |                   |                          |
|   |        |           |                   |                          |
| T |        |           |                   |                          |
| . |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+
| # |        |           |                   |                          |
|   |        |           |                   |                          |
|   |        |           |                   |                          |
| I |        |           |                   |                          |
| . |        |           |                   |                          |
| L |        |           |                   |                          |
| . |        |           |                   |                          |
|   |        |           |                   |                          |
|   |        |           |                   |                          |
| C |        |           |                   |                          |
| R |        |           |                   |                          |
|   |        |           |                   |                          |
|   |        |           |                   |                          |
| C |        |           |                   |                          |
| O |        |           |                   |                          |
| N |        |           |                   |                          |
| T |        |           |                   |                          |
|   |        |           |                   |                          |
+---+--------+-----------+-------------------+--------------------------+

WHEN MAILING FOLD THIS SECTION INSIDE