You’re Agency Name Here
ANIMAL BITE REPORT
Rabies Management Program
Date: ______Dispatch #: ______Case #: ______
HUMAN (Victim) IDENTIFICATION
Name: ______DOB: ______Male Female
Address: ______Phone: home ______/ work ______
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If minor, Parent / Guardian: ______Relationship: ______
Address (if different): ______Phone: home ______/ work ______
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Did victim have a rabies prevention immunization prior to incident? Yes No Unknown
DOMESTIC ANIMAL (Victim) IDENTIFICATION (if animal contact)
Type of animal: ______owned stray wild
Description: ______male female age:______
Owner: ______Phone: home ______/ work ______
Address: ______
Date of current rabies vaccination: ______Veterinarian: ______Phone: ______
License No.: ______State:______Clinic:______Rabies Tag #______Exp. Date:_____
SUSPECT ANIMAL IDENTIFICATION
Type of animal: ______owned stray wild
Description: ______male female age:______
Owner: ______Phone: home ______/ work ______
Address: ______
Date of current rabies vaccination: ______Veterinarian: ______Phone: ______
License No.: ______State:______Clinic:______Rabies Tag #______Exp. Date:_____
Date reported: ______Reported by: ______Date of bite:______
Type of contact: bite scratch other (specify):______
Body part(s) bitten and/or scratched: ______
Medical care required? yes no. If yes, hospital & doctor:______
Was rabies exposure prophylaxis given to victim? yes no unknown
Has animal been ill, acting strangely, or bitten anyone recently? Yes No
If yes, please explain:______
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Was attack provoked? yes no
Please describe incident: ______
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DISPOSITION OF ANIMAL
Owner’s possession - Euthanized / sent to HETL for testing - Veterinary Hospital - Unknown
Animal Shelter - Boarding Kennel - Other (specify):______
Name of facility & location:______
Date of Quarantine:______Date of release:______Veterinary checked? yes no
DISPOSITION OF SUSPECT ANIMAL
Owner’s possession - Euthanized / sent to HETL for testing - Veterinary Hospital - Unknown
Animal Shelter - Boarding Kennel - Other (specify):______
Name of facility & location:______
Date of Quarantine:______Date of release:______Veterinary checked? yes no
INVESTIGATING OFFICER
Name:______Signature:______
Enforcement: Rabies Advisory Notice Quarantine Notice Summonses Other______
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