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STUDY NUMBER 9321-08-XXX Page 1 of 2 Form CLT-3a: Results Report Form for use of Chloramine-T under INAD 9321 - All salmonids treated for BGD at 12 - 20 mg/L; treatment on 3 consecutive or 3 alternate days INSTRUCTIONS 1. Investigator must fill out Form CLT-3A no later than 10 days after completion of the 14-day post-treatment observation period. Study Number must be recorded on all pages of Form CLT-3A. Attach lab reports and other information. 2. If Chloramine-T 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 Bozeman NIO for inclusion in the permanent file. 4. Note: Both Investigator and Study Monitor should sign and date Form CLT-3A. SITE INFORMATION Facility Fish Hatchery A Reporting Individual John Doe TREATMENT INFORMATION AND SCHEDULE Drug lot number 111222C Total amount drug used (kg) Fish species treated Steelhead trout CLT dosage used (mg/L) Disease treated BGD Disease diagnosed by Average fish weight (gm) 4.4 6.12 Average fish length (in) 15 Josey Jo 3.0 Number of fish per unit (e.g. 10,000 fish/raceway) 47,782 Number of treated units 3 Total number of treated fish 143,346 Number of control units 0 Total number of control fish 0 X Flow through Check type of treatment A Check treatment objective Dates of treatment (disease control) Standing bath 1st X 8/23/08 Date treatment started (disease prevention) 2nd B C D 8/24/08 3rd 8/25/08 Date treatment ended (disease prevention) WATER QUALITY PARAMETERS Ave pre-treatment temp (oF) 57 Dissolved Oxygen (mg/L) 8.6 Ave treatment temp (oF) 57 pH 7.7 Ave post-treatment temp (oF) 57 Hardness - CaCO3 (mg/L) 300 Form CLT-3A Results Report Form Revised 08/07 RESULTS: Describe in detail treatment results. Was treatment successful? 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? Treatment was successful. Mortality decreased following the first day of treatment and returned to normal levels during the post-treatment period. Pathology Report: Attach pathology report to this form. Report should include: 1) a description of how the pathogen(s) was identified; 2) disease identification records that confirm the presence of the pathogen; and 3) the name and title of the individual performing the diagnosis. Pathology Report included: X pre-treatment X post-treatment Toxicity observations: Report any apparent drug toxicity including a description of unusual fish behavior. none DRUG DISCHARGE RESULTING FROM THIS TREATMENT: Use Addendum 2: Discharge Worksheet for calculations and attach completed Discharge Worksheet to this form. Enter the value from Addendum 2 step 3 in this space. 0.28 ppm calculated; however, actual measurement was 0.005 ppm OBSERVED WITHDRAWAL PERIOD OF TREATED FISH: X Investigator should initial here to indicate awareness that fish disposition must be in compliance with FDA-mandated withdrawal times as described in Section VI, B, page 3 of the Study Protocol. Estimated number of days between last treatment and first availability of fish for human consumption (ensure this time period meets the withdrawal period). 1 yr NEGATIVE REPORT Chloramine-T 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 Prepared: 8/31/08 Investigator: Sign here Date Reviewed: 8/31/08 Study Monitor: Sign here Form CLT-3A Results Report Form Revised 08/07