Appendix IX escape notification form

This webpage is intended for informational purposes only.

Licence Holder Name:

Contact Name:

Contact Phone No:

Contact Email:

Facility Name:

Facility Reference No:

Current Licence No:

Reporting Submission Date:

Escape Date (YYYY-MMDD)
Incident Time (HH:MM)(24hrs)      
Escaped Species (Common Name)      
Estimated Number Escaped      
Average Weight(grams)      
Date Stocked (YYYY-MMDD)      
Stock Source Facility Name      
Drug Administered (Name of Drug*)      
Treatment Start Date (YYYY-MMDD)      
Treatment End Date (YYYY-MMDD)      
Prescribing Veterinarian Name      
Prescribed Withdrawal Period      
Inventory Lots Treated **      

Pick Lists:

Escaped Species type:

  • Atlantic
  • Chinook
  • Coho
  • Halibut
  • Pilchard
  • Rainbow
  • Rockfish
  • Sablefish
  • Sockeye
  • Steelhead
  • Wolf Eel
  • Other

Drug Type

  • No Drug
  • Oxytetracycline
  • Florfenicol
  • Tribrissen
  • Romet
  • Emamectin
  • Erythromycin
  • TMS
  • Metomidate
  • Clove Oil
  • Other - explain in comments

Incident Cause***:

 

 

 

 

 

Planned Mitigation Measures***:

 

 

 

 

 

Comments:

 

 

 

 

 

List each therapeutants (still within the prescribed withdrawal period) administered to these finfish

** Identification of the groups/pens #s of finfish treated

*** Describe in detail