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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION
OWNER

REPORT OF TUBERCULIN TESTS OF CATTLE REQUIRED FOR INTRODUCTION INTO THE UNITED STATES OF RAW MILK AND CREAM UNDER THE FEDERAL IMPORT MILK ACT
DATE OF EXAMINATION

Form Approved; OMB No. 0910-0212 Expiration Date: June 30, 2012 See Reverse for OMB Statement

ADDRESS

LOCATION OF HERD

A N I M A L N O 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

SUBCUTANEOUS A G E S E X IDENTIFICATION OF ANIMAL (Accurate description or ear tag number or registration name and number) TEMPERATURE BEFORE INJECTION
M M M

TIME OF INJECTION
M

TUBERCULIN INJECTION 1 QTY/TYPE
C.C. TYPE

TEMPERATURE AFTER INJECTION

INTRADERMAL INJECTION Type Quantity Date Hour
M OBSERVATIONS hrs hrs hrs

CONCLUSIONS (healthy, reactor, suspect)

2

M

M

M

M

M

IF MORE SPACE IS NEEDED USE ADDITIONAL FORMS FDA 1994 CERTIFICATION: I HEREBY CERTIFY THAT I HAVE INSPECTED AND TESTED WITH TUBERCULIN THE SIGNATURE OF VETERINARIAN TITLE (Official connection) ANIMALS ABOVE WITH RESULTS AS STATED. MAILING ADDRESS (Include ZIP Code)

1. The following symbols may be used to denote the type of tuberculin: B - Bovine; A - Avian; & H - Human. 2. All reactors & suspicious animals must be removed from herd & certificate of owner to that effect given on the other side of this form.

FORM FDA 1994 (8/09)

PREVIOUS EDITION IS OBSOLETE

PSC Graphics (301) 443-1090

EF

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 and 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: Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer (HFA-710) 5600 Fishers Lane Rockville, MD 20857 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)

FORM FDA 1994 (8/09)