,,ii #aac? ,,congress #a/ ,session ,s4 #abef ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,june #bg1 #bjac ,mrs4 ,fe9/e9 7= h]self1 ,ms4 ,coll9s1 ,mr4 ,re$1 ,ms4 ,cantwell1 & ,mrs4 ,box]7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ,a ,,bill ,to am5d ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act to pres]ve ! effectiv5ess ( m$ically important antimicrobials us$ 9 ! treatm5t ( human & animal diseases4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,prev5t+ ,antibiotic ,resi/ance ,act ( #bjac4 #b4 ,f9d+s ,! ,congress f9ds ! foll[+3 7#a7 7,a7 ,9 #aigg1 ! ,food & ,drug ,adm9i/ration conclud$ t fe$+ live/ock l[ doses ( antibiotics us$ 9 human disease treatm5t c\ld promote ! developm5t ( antibiotic-resi/ance 9 bact]ia4 ,h[ev]1 ! ,food & ,drug ,adm9i/ration did n act 9 response to ^! f9d+s1 despite laws requir+ ! ag5cy to d s4 7,b7 ,9 #bjab1 ! ,food & ,drug ,adm9i/ration 0 ord]$ by a ,f$]al c\rt to address ! use ( antibiotics 9 live/ock1 z ! result ( a lawsuit fil$ aga9/ ! ag5cy cit+ ! ag5cy's failure to act 9 response to ! #aigg f9d+s4 7#b7 7,a7 ,9 #aiih1 ! ,national ,academy ( ,sci5ces not$ t antibiotic-resi/ant bact]ia g5]ate a m9imum ( #d1jjj1jjj1jjj to #e1jjj1jjj1jjj 9 co/s to ,unit$ ,/ates society & individuals ye>ly4 7,b7 ,9 #bjji1 ,cook ,c\nty ,hospital & ! ,alliance = ,prud5t ,use ( ,antibiotics e/imat$ t ! total heal? c>e co/ ( antibiotic resi/ant infections 9 ! ,unit$ ,/ates 0 betwe5 #af1fjj1jjj1jjj & #bf1jjj1jjj1jjj annually4 7#c7 ,an ,april #aiii /udy by ! ,gov]nm5t ,acc\ntability ,(fice conclud$ t resi/ant /ra9s ( #c microorganisms t cause foodborne illness or disease 9 humans 7,salmonella1 ,campylobact]1 & ,e4 coli7 are l9k$ to ! use ( antibiotics 9 animals4 7#d7 7,a7 ,l>ge-scale1 volunt>y surveys by ! ,dep>tm5t ( ,agriculture's ,animal & ,plant ,heal? ,inspection ,s]vice 9 #aiii1 #bjja1 & #bjjf reveal$ t-- 7i7 #hd p]c5t ( gr[]-f9i%] sw9e f>ms1 #hc p]c5t ( cattle fe$lots1 & #hd p]c5t ( %eep f>ms adm9i/] antimicrobials 9 ! fe$ or wat] = heal? or gr[? promotion reasons2 & 7ii7 _m ( ! antimicrobials id5tifi$ are id5tical or closely relat$ to drugs us$ 9 human m$ic9e1 includ+ tetracycl9es1 macrolides1 ,bacitrac91 p5icill9s1 & sulfonamides4 7,b7 ,su* drugs are us$ 9 p to treat s]i\s diseases su* z pneumonia1 sc>let fev]1 rheumatic fev]1 sexually transmitt$ infections1 sk9 infections1 & ev5 p&emics l mal>ia & plague1 z well z biot]rorism ag5ts su* z an?rax4 7#e7 7,a7 ,any ov]use or misuse ( antibiotics contributes to ! spread ( antibiotic resi/ance1 :e!r 9 human m$ic9e or 9 agriculture4 7,b7 ,recogniz+ ! public heal? ?reat caus$ by antibiotic resi/ance1 ,congress took sev]al /eps to curb antibiotic ov]use 9 human m$ic9e ?r\gh am5dm5ts to ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bja et seq47 made by section #ajb ( ! ,public ,heal? ,?reats & ,em]g5cies ,act 7,public ,law #ajf-eje2 #aad ,/at4 #bcae71 b has n yet address$ antibiotic ov]use 9 agriculture4 7#f7 ,9 ,janu>y #bjja1 a ,f$]al int]ag5cy task =ce-- 7,a7 releas$ an action plan to address ! cont9u+ decl9e 9 effectiv5ess ( antibiotics aga9/ common bact]ial infections1 ref]r$ to z antibiotic resi/ance2 7,b7 det]m9$ t antibiotic resi/ance is a gr[+ m5ace to all p & poses a s]i\s ?reat to public heal?2 & 7,c7 caution$ t if curr5t tr5ds cont9ue1 treatm5ts = common infections w become increas+ly limit$ & exp5sive1 &1 9 "s cases1 nonexi/5t4 7#g7 ,! ,unit$ ,/ates ,geological ,survey report$ 9 ,m>* #bjjb t-- 7,a7 antibiotics 7 pres5t 9 #dh p]c5t ( ! /reams te/$ nationwide2 & 7,b7 almo/ half ( ! te/$ /reams 7 d[n/ream f agricultural op]ations4 7#h7 ,! pe]-review$ j\rnal ,cl9ical ,infecti\s ,diseases publi%$ a report 9 ,june #bjjb t-- 7,a7 0 bas$ on a #b-ye> review by exp]ts 9 human & vet]9>y m$ic9e1 public heal?1 microbiology1 bio/ati/ics1 & risk analysis1 ( m ?an #ejj sci5tific /udies on ! human heal? impacts ( antimicrobial use 9 agriculture2 & 7,b7 recomm5d$ t antimicrobial ag5ts %\ld no long] be us$ 9 agriculture 9 ! abs5ce ( disease1 b %\ld be limit$ to !rapy = diseas$ individual animals & prophylaxis :5 disease is docum5t$ 9 a h]d or flock4 7#i7 ,9 a ,m>* #bjjc report1 ! ,national ,academy ( ,sci5ces /at$ t-- 7,a7 a decrease 9 antimicrobial use 9 human m$ic9e alone w h little effect on ! curr5t situation2 & 7,b7 sub/antial ef=ts mu/ be made to decrease inappropriate ov]use 9 animals & agriculture4 7#aj7 ,! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cja et seq47-- 7,a7 requires t all drugs be %[n to be safe be=e ! drugs are approv$2 & 7,b7 places ! burd5 on manufactur]s to acc\nt = heal? consequ5ces & prove safety4 7#aa7 7,a7 ,9 #bjjc1 ! ,food & ,drug ,adm9i/ration modifi$ ! drug approval process = antibiotics to recognize ! developm5t ( resi/ant bact]ia z an important aspect ( safety1 b mo/ antibiotics curr5tly us$ 9 animal production sy/ems = non!rapeutic purposes 7 approv$ be=e ! ,food & ,drug ,adm9i/ration began consid]+ resi/ance dur+ ! drug-approval process4 7,b7 ,! ,food & ,drug ,adm9i/ration has n e/abli%$ a s*$ule = review+ ^? exi/+ approvals4 7#ab7 7,a7 ,9 an ,april #bjjd report1 ! ,gov]nm5t ,acc\ntability ,(fice-- 7i7 conclud$ t ,f$]al ag5cies d n collect ! critical data on antibiotic use 9 animals t !y ne$ to support rese>* on human heal? risks2 & 7ii7 recomm5d$ t ! ,dep>tm5t ( ,agriculture & ! ,dep>tm5t ( ,heal? & ,human ,s]vices develop & implem5t a plan to collect data on antibiotic use 9 animals4 7,b7 ,9 a ,septemb] #bjaa update to t report1 ! ,gov]nm5t ,acc\ntability ,(fice-- 7i7 conclud$ t ,f$]al ag5cies _h made limit$ progress 9 address+ antibiotic use 9 animals2 7ii7 recomm5d$ t ,f$]al ag5cies fund rese>* on alt]natives to curr5t antibiotic use practices2 & 7iii7 recomm5d$ t ,f$]al ag5cies track ! effectiv5ess ( policies t curb antibiotic resi/ance1 includ+ ! ,food & ,drug ,adm9i/ration's volunt>y guidel9es r$uc+ antibiotic use 9 food animals4 7#ac7 ,9 #bjji1 ! ,congressional ,rese>* ,s]vice conclud$ t1 )\t re/rictions on ! use ( antimicrobial drugs 9 ! production ( live/ock1 export m>kets = live/ock & p\ltry c\ld be negatively impact$ due to re/rictions on ! use ( antibiotics 9 o!r nations4 7#ad7 ,9 #bjaj1 ! pe]-review$ j\rnal ,molecul> ,cell publi%$ a /udy demon/rat+ t l[-dosage use ( antibiotics causes a dramatic increase 9 g5etic mutation1 rais+ new conc]ns ab\t ! agricultural practice ( us+ l[-dosage antibiotics 9 ord] to /imulate gr[? promotion & r\t9ely prev5t disease 9 unheal?y conditions4 7#ae7 ,9 #bjaj1 ! ,dani% ,vet]9>y & ,food ,adm9i/ration te/ifi$ t ! ,dani% ban ( ! non!rapeutic use ( antibiotics 9 food animal production result$ 9 a m>k$ r$uction 9 antimicrobial resi/ance 9 multiple bact]ial species1 includ+ ,campylobact] & ,ent]ococci4 7#af7 ,9 #bjaa1 ! ,food & ,drug ,adm9i/ration det]m9$ t-- 7,a7 #ac1ejj1jjj kilograms ( antibact]ial drugs 7 sold = use on food animals 9 ! ,unit$ ,/ates 9 #bjaj2 7,b7 #c1cjj1jjj kilograms ( antibact]ial drugs 7 us$ = human heal? 9 #bjaj2 & 7,c7 #hj p]c5t ( antibact]ial drugs dissem9at$ 9 ! ,unit$ ,/ates 9 #bjaj 7 sold = use on food animals1 r ?an be+ us$ = human heal?4 7#ag7 ,9 #bjaa1 a review ( all sci5tific /udies on antimicrobial use 9 f>m animals1 publi%$ 9 ,cl9ical ,microbiology ,reviews1 f\nd t-- 7,a7 use ( antibiotics 9 food animals leads to developm5t ( res]voirs ( antibiotic resi/ance2 7,b7 a ban on non!rapeutic antibiotic use 9 food animals w\ld pres]ve ! use ( su* antibiotics = m$ic9e2 & 7,c7 a ,dani% ban on non!rapeutic antibiotics 9 food animals result$ 9 little *ange 9 animal morbidity & mortality1 & only a mode/ increase 9 production co/4 7#ah7 ,9 ,april #bjab1 ! ,food & ,drug ,adm9i/ration issu$ volunt>y guidance to indu/ry on r$uc+ antibiotic use 9 live/ock & p\ltry4 ,z "p ( t guidance1 x summ>iz$ ov] #ce ye>s ( pe]-review$ sci5tific lit]ature reg>d+ use ( antimicrobial drugs 9 live/ock4 ,z a result1 ! ,food & ,drug ,adm9i/ration /at$ /rategies = controll+ antibiotic resi/ance are ne$$1 & are seek+ volunt>ily limits on antibiotic use4 7#ai7 7,a7 ,9 ,janu>y #bjac1 ,consum] ,reports publi%$ te/ results on pork products b\ght 9 groc]y /ores nationwide %[+ di/urb+ly high levels ( ,salmonella & ,y]s9ia ent]ocolitica bact]ia t 7 resi/ant to ! antibiotics us$ to treat foodborne illnesses4 ,a #bjjc ,consum] ,report /udy %[$ simil> results 9 p\ltry products4 7,b7 ,! ,food & ,drug ,adm9i/ration's ,national ,antimicrobial ,resi/ance ,monitor+ ,sy/em r\t9ely f9ds t retail meat products are contam9at$ ) bact]ia 7includ+ ! foodborne pa?og5s ,campylobact] & ,salmonella7 t are resi/ant to antibiotics important 9 human m$ic9e4 ,! #bjaa ,national ,antimicrobial ,resi/ance ,monitor+ ,sy/em report f\nd t ! p]c5tage ( meat conta9+ antibiotic resi/ant bact]ia increases ea* ye> & t _m ( ^! bact]ia exhibit multiple antibiotic resi/ance4 7#bj7 ,antibiotic resi/ance1 result+ 9 a r$uc$ numb] ( effective antibiotics1 may significantly impair ! ability ( ! ,unit$ ,/ates to respond to t]rori/ attacks involv+ bact]ial infections or a l>ge influx ( hospitaliz$ pati5ts4 7#ba7 ,_m sci5tific /udies confirm t ! non!rapeutic use ( antibiotics 9 agricultural animals contribute to ! developm5t ( antibiotic-resi/ant bact]ial infections 9 p4 7#bb7 ,epidemiological rese>* has %[n t resi/ant ,salmonella & ,campylobact] infections are associat$ ) increas$ numb]s ( ill pati5ts & blood/ream infections1 & increas$ dea?4 7#bc7 ,! ,am]ican ,m$ical ,association1 ! ,am]ican ,public ,heal? ,association1 ! ,national ,association ( ,c\nty & ,city ,heal? ,(ficials1 & ! ,national ,su/a9able ,agriculture ,coalition are among ! m ?an #djj organizations repres5t+ heal?1 consum]1 agricultural1 environm5tal1 humane1 & o!r int]e/s t h support$ enactm5t ( legislation to phase out non!rapeutic use 9 f>m animals ( m$ically important antimicrobials4 #c4 ,purpose ,! purpose ( ?is ,act is to pres]ve ! effectiv5ess ( m$ically important antimicrobials us$ 9 ! treatm5t ( human & animal diseases4 #d4 ,pro( ( safety ( m$ically important antimicrobials 7a7 ,applications p5d+ or submitt$ aft] enactm5t ,section #eab7;d77#a7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cfj;b7d77#a77 is am5d$-- 7#a7 9 ! fir/ s5t5ce-- 7,a7 9 subp>agraph 7,h71 by /rik+ or at ! end2 7,b7 9 subp>agraph 7,i71 by ins]t+ or at ! end2 & 7,c7 by ins]t+ aft] subp>agraph 7,i7 ! foll[+3 7,j7 ) respect to a m$ically important antimicrobial 7z def9$ 9 subsection 7q771 ! applicant has fail$ to demon/rate t !re is a reasonable c]ta9ty ( no h>m to human heal? due to ! developm5t ( antimicrobial resi/ance t is attributable1 9 :ole or 9 "p1 to ! non!rapeutic use 7z def9$ 9 subsection 7q77 ( ! m$ically important antimicrobial or drug2 2 & 7#b7 9 ! second s5t5ce1 by /rik+ 7,a7 ?r\gh 7,i7 & ins]t+ 7,a7 ?r\gh 7,j74 7b7 ,phas$ elim9ation ( non!rapeutic use 9 animals ( m$ically important antimicrobials ,section #eab ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cfj;b7 is am5d$ by add+ at ! end ! foll[+3 7q7 ,phas$ elim9ation ( non!rapeutic use 9 animals ( m$ically important antimicrobials 7#a7 ,applicability ,?is subsection applies to ! non!rapeutic use 9 a food-produc+ animal ( a drug-- 7,a7 t is a m$ically important antimicrobial2 7,b7 = :i* !re is 9 effect an approval ( an application or an exemption "u subsection 7b71 7i71 or 7j7 ( section #eje2 or 7,c7 t is o!rwise m>ket$ = human use4 7#b7 ,)drawal ,! ,secret>y %all )draw ! approval ( a non!rapeutic use 9 food-produc+ animals ( a drug describ$ 9 p>agraph 7#a7 on ! date t is #b ye>s aft] ! date ( enactm5t ( ?is subsection unless-- 7,a7 be=e ! date t is #b ye>s aft] ! date ( ! enactm5t ( ?is subsection1 ! ,secret>y makes a f9al writt5 det]m9ation t ! hold] ( ! approv$ application has demon/rat$ t !re is a reasonable c]ta9ty ( no h>m to human heal? due to ! developm5t ( antimicrobial resi/ance t is attributable 9 :ole or 9 "p to ! non!rapeutic use ( ! drug2 or 7,b7 be=e ! date specifi$ 9 subp>agraph 7,a71 ! ,secret>y makes a f9al writt5 det]m9ation "u ?is subsection1 ) respect to a risk analysis ( ! drug conduct$ by ! ,secret>y & o!r relevant in=mation1 t !re is a reasonable c]ta9ty ( no h>m to human heal? due to ! developm5t ( antimicrobial resi/ance t is attributable 9 :ole or 9 "p to ! non!rapeutic use ( ! drug4 7#c7 ,exemptions ,except z provid$ 9 p>agraph 7#e71 if ! ,secret>y grants an exemption "u section #eje7;i7 = a drug t is a m$ically important antimicrobial1 ! ,secret>y %all resc9d ea* approval ( a non!rapeutic use 9 a food-produc+ animal ( ! m$ically important antimicrobial1 effective on ! date t is #b ye>s aft] ! date on :i* ! ,secret>y grants ! exemption4 7#d7 ,approvals ,except z provid$ 9 p>agraph 7#e71 if an application = a drug t is a m$ically important antimicrobial is submitt$ to ! ,secret>y "u section #eje7;b71 ! ,secret>y %all resc9d ea* approval ( a non!rapeutic use 9 a food-produc+ animal ( ! m$ically important antimicrobial1 effective on ! date t is #b ye>s aft] ! date on :i* ! application is submitt$ to ! ,secret>y4 7#e7 ,exceptions ,p>agraph 7#c7 or 7#d71 z applicable1 %all n apply if-- 7,a7 be=e ! date on :i* approval w\ld be resc9d$ "u t p>agraph1 ! ,secret>y makes a f9al writt5 det]m9ation t ! hold] ( ! application = ! approv$ non!rapeutic use has demon/rat$ t !re is a reasonable c]ta9ty ( no h>m to human heal? due to ! developm5t ( antimicrobial resi/ance t is attributable 9 :ole or 9 "p to ! non!rapeutic use 9 ! food-produc+ animal ( ! m$ically important antimicrobial2 or 7,b7 be=e ! date specifi$ 9 subp>agraph 7,a71 ! ,secret>y makes a f9al writt5 det]m9ation1 ) respect to a risk analysis ( ! m$ically important antimicrobial conduct$ by ! ,secret>y & any o!r relevant in=mation1 t !re is a reasonable c]ta9ty ( no h>m to human heal? due to ! developm5t ( antimicrobial resi/ance t is attributable 9 :ole or 9 "p to ! non!rapeutic use ( ! m$ically important antimicrobial4 7#f7 ,def9itions ,9 ?is subsection3 7,a7 ,! t]m m$ically important antimicrobial means a drug t-- 7i7 is int5d$ = use 9 food-produc+ animals2 & 7ii7 is compos$ :olly or p>tly (-- 7,i7 any k9d ( p5icill91 tetracycl9e1 macrolide1 l9cosamide1 /reptogram91 am9oglycoside1 sulfonamide1 or cephalospor92 or 7,,ii7 a drug f an antimicrobial class t is li/$ z highly important1 critically important1 or important by ! ,_w ,heal? ,organization 9 ! late/ edition ( its publication entitl$ ,critically ,important ,antimicrobials = ,human ,m$ic9e 7or a successor publication74 7,b7 ,! t]m !rapeutic use1 ) respect to a m$ically important antimicrobial1 means ! use ( antimicrobials = ! specific purpose ( treat+ an animal ) a docum5t$ disease or infection4 ,su* t]m does n include ! cont9u$ use ( su* an antimicrobial 9 ! animal aft] ! disease or infection is resolv$4 7,c7 ,! t]m non!rapeutic use-- 7i7 means adm9i/ration ( antibiotics to an animal ?r\gh fe$ or wat] 7or1 9 p\ltry hat*]ies1 ?r\gh any means7 = purposes 7su* z gr[? promotion1 fe$ effici5cy1 weight ga91 or disease prev5tion7 o!r ?an !rapeutic use or nonr\t9e disease control2 & 7ii7 includes any repeat$ or regul> patt]n ( use ( m$ically important antimicrobials = purposes o!r ?an !rapeutic use or nonr\t9e disease control4 7,d7 ,! t]m noncu/om>y situation does n include normal or /&>d practice & conditions on ! premises t facilitate ! transmission ( disease4 7,e7 ,! t]m nonr\t9e disease control means ! use ( antibiotics 9 ! fe$ or wat] ( an animal t is n sick1 :]e x c be %[n t a p>ticul> disease or infection is1 or is likely to be1 pres5t on ! premises because ( a specific1 non-cu/om>y situation4 4 #e4 ,limitations on use ( m$ically important antimicrobials = nonr\t9e disease control 7a7 ,prohibit$ acts ,section #cja ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cca7 is am5d$ by add+ at ! end ! foll[+3 7ccc7 ,! adm9i/ration ( a m$ically important antimicrobial to a food-produc+ animal = nonr\t9e disease control 9 violation ( ! requirem5ts ( section #eab;,a4 4 7b7 ,requirem5ts ,*apt] ,v ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act is am5d$ by ins]t+ aft] section #eab ( su* ,act 7#ba ,u4,s4,c4 #cfj;b7 ! foll[+3 #eab;,a4 ,limitations on use ( m$ically important antimicrobials = nonr\t9e disease control 7a7 ,prohibition ,x %all be unlawful to adm9i/] 7includ+ by means ( animal fe$7 a m$ically important antimicrobial to a food-produc+ animal = nonr\t9e disease control unless-- 7#a7 7,a7 !re is a significant risk t a disease or infection pres5t on1 or likely pres5t on1 ! premises w be transmitt$ to ! food-produc+ animal2 7,b7 ! adm9i/ration ( ! m$ically important antimicrobial to ! food-produc+ animal is necess>y to prev5t or r$uce ! risk ( transmission ( ! disease or infection describ$ 9 p>agraph 7#a72 7,c7 ! m$ically important antimicrobial is adm9i/]$ to ! food-produc+ animal = nonr\t9e disease control = ! %orte/ duration possible to prev5t or r$uce ! risk ( transmission ( ! disease or infection describ$ 9 p>agraph 7#a7 to ! animal2 & 7,d7 ! m$ically important antimicrobial is adm9i/]$-- 7i7 at a scale no great] ?an ! b>n1 h\se1 or p5 level2 & 7ii7 to ! fewe/ animals possible to prev5t or r$uce ! risk ( transmission ( ! disease or infection describ$ 9 p>agraph 7#a72 or 7#b7 ! ,secret>y det]m9es t !re is a reasonable c]ta9ty ( no h>m to human heal? due to ! developm5t ( antimicrobial resi/ance t is attributable 9 :ole or 9 "p to su* use ( ! m$ically important antimicrobial & su* use does n ?reat5 ! public heal?4 7b7 ,def9itions ,9 ?is section3 7#a7 ,! t]m food-produc+ animal means a food-produc+ animal int5d$ = sale 9 int]/ate comm]ce4 7#b7 ,! t]ms m$ically important antimicrobial & nonr\t9e disease control h ! mean+s giv5 su* t]ms 9 section #eab7q74 4 7c7 ,applicability ,! am5dm5ts made by ?is section apply beg9n+ on ! date t is #b ye>s aft] ! date ( ! enactm5t ( ?is ,act4 #f4 ,s5se ( ! ,s5ate reg>d+ vet]9>y ov]sight ( use ( m$ically important antimicrobials 7a7 ,9 g5]al ,x is ! s5se ( ! ,s5ate t a valid vet]9>ian-cli5t-pati5t relation%ip %\ld exi/ to ensure t m$ically important antimicrobials are us$ 9 a mann] t is consi/5t ) pr(essionally accept$ be/ practices4 7b7 ,vet]9>ian-,cli5t-,pati5t relation%ip ,9 ?s section1 ! t]m vet]9>ian-cli5t-pati5t relation%ip means a relation%ip 9 :i* all ( ! foll[+ crit]ia are met3 7#a7 ,! vet]9>ian has assum$ ! responsibility = mak+ m$ical judgm5ts reg>d+ ! heal? ( ! pati5t & ! cli5t has agre$ to foll[ ! vet]9>ian's in/ructions4 7#b7 ,! vet]9>ian has suffici5t k ( ! pati5t to initiate at lea/ a g5]al or prelim9>y diagnosis ( ! m$ical condition ( ! pati5t4 ,?is means t ! vet]9>ian is p]sonally acqua9t$ ) ! keep+ & c>e ( ! pati5t by virtue (-- 7,a7 a timely exam9ation ( ! pati5t by ! vet]9>ian2 or 7,b7 m$ically appropriate & timely visits by ! vet]9>ian to ! premises :]e ! animal or animals are kept4 7#c7 ,! vet]9>ian is readily available = foll[-up evaluation or has arrang$ = vet]9>y em]g5cy cov]age & cont9u+ c>e & treatm5t4 7#d7 ,! vet]9>ian provides ov]sight ( treatm5t1 compliance1 & outcome4 7#e7 ,pati5t records are ma9ta9$4