Rabies Exposure Reporting Form
Date of report
-
Month
-
Day
Year
Date
Exposure reported to Animal Control
Yes
No
Victim to report
Reporter Name
First Name
Last Name
Reporter Facility
Reporter Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Person reporting bite
Health care provider
Veterinarian
Bite victim/parent or guardian
Victim Name
First Name
Last Name
Victim Date of birth
-
Month
-
Day
Year
Date
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Sex
Male
Female
Other
Race
Amer Ind/AK Native
Native HI/ Other PI
White
Asian
Black/ Af. Aer
Unknown
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Date of Exposure
-
Month
-
Day
Year
Date
Place exposure occurred
Provoked?
Yes
No
Unknown
Location of bite/scratch
Leg
Head
Torso
Arm
Hand/Finger
Other
Animal Type
Dog
Cat
Bat
Ferret
Other
Wound cleaned?
Please Select
Yes
No
Tetanus Immunization
Please Select
Yes
No
Up-to-date
Date of Last Tetanus Immunization
-
Month
-
Day
Year
Date
Describe exposure scenario/Notes
Animal status
Owned
Stray
Wild
Unknown
Owner's Name
Owner's Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is the animal up-to-date with its rabies vaccine?
Yes
No
Unknown
Date
-
Month
-
Day
Year
Date
Vet Information
Veterinarian name
Facility Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Animal disposition
10 day quarantine
Euthanized and tested
At large/unavailable
Unknown
Other
Submit
Should be Empty: