Appendix: Animal Tissue Form - For Veterinary Products only

1. Does this veterinary product contain or is it produced using animal-sourced material (either as an active ingredient, excipient/capsular material and/or auxiliary reagent)?

Yes (If yes please proceed with 2.)
No

2. Please complete a separate animal tissue form for each animal-sourced material. The animal-sourced material is used as an:

Active Ingredient
Excipient/Capsular material
Auxiliary Reagent

3. Naming Information:

1. Brand or Proprietary name of animal-derived active ingredient, excipient/capsular material and/or auxiliary reagent
   
   
2. Chemical Name of animal-derived active ingredient, excipient/capsular material and/or auxiliary reagent

4. Type of animal from which the animal material is derived:

Bovine (cattle)

Bison

Water buffalo (Bubalus bubalis)

Ovine (sheep)

Caprine (goat)

Porcine (pig)

Elk (wapiti)

Deer

Chicken

Other

5. Is this veterinary therapeutic product intended for food producing animals?

Yes (If yes please identify and proceed with 6,7 and 8)
No

6. Animal Tissue and/or Fluid Used:

Fluid:

bile

blood/blood products

cerebrospinal fluid (CSF)

colostrum

cord blood

milk and/or milk products

placental fluids

saliva

urine

Tissue:

adipose tissue/omentum

adrenal gland or adrenal tissue

antler velvet

Appendix

bones (other than skull and vertebral column)

bone marrow

brain/cerebellum/brain stem

cartilaginous tissue (trachea etc.)

cornea

distal ileum

dorsal root ganglia

dura mater

embryonic tissue/fetal tissue

enzymes (please specify)

eyes/retina/optic nerve

gall bladder

heart/pericardium

hypothalamus

kidney

large intestine

liver

lung

lymph nodes

other:

mammary gland

muscle, skeletal (please specify)

muscle, smooth (please specify)

ovary

pancreas

pituitary gland

placenta

salivary gland

skins and hides

skull

small intestine (other than distal ileum)

spinal cord

spleen

stomach/abomasum

tendons/ligaments

testis

thymus

thyroid/parathyroid

tonsils

trigeminal ganglia

vertebral column

7. Age of animal used (in months):

Under
or Range from
to

8. * Country of origin (birth) of animal used to derive material:

*If the animal was raised and/or slaughtered in a country other than the country of origin, please list the country or countries.