Form Center

2. TOWNSHIP/VILLAGE where incident occurred*
3. COUNTY*
5. ADDRESS where incident occurred
7. DATE and TIME of incident
   DATE and TIME of incident

   DATE and TIME of incident
8. Who was bitten/exposed?*

   1. HUMAN
   2. DOMESTIC ANIMAL
12. BITE VICTIM INFORMATION
14. NAME
15. DATE OF BIRTH
    DATE OF BIRTH
16. PARENT NAME (if child)
18. ADDRESS
19. PHONE
21. SITE OF BITE/SCRATCH
22. SKIN BROKEN?

    1. YES
    2. NO
23. BITTEN THROUGH CLOTHING?

    1. YES
    2. NO
25. WOUND TREATMENT
26. DATE OF TREATMENT
    DATE OF TREATMENT
27. ANTI-RABIES PROPHYLAXIS GIVEN?

    1. YES
    2. NO
29. ANIMAL NAME
30. TYPE OF ANIMAL
31. BREED
32. AGE
34. OWNER NAME
35. OWNER PHONE
37. DESCRIBE INJURIES
39. WOUND TREATMENT
40. VETERINARIAN
42. RABIES VACCINATION?

    1. YES
    2. NO
43. WHERE GIVEN?
44. ANIMAL CURRENTLY ALIVE?

    1. YES
    2. NO
46. ANIMAL'S CURRENT LOCATION
50. BITING ANIMAL INFORMATION
52. TYPE OF ANIMAL*
53. STATUS*

    1. DOMESTIC ANIMAL
    2. WILD/FERAL ANIMAL
54. COLOR
56. ANIMAL NAME
57. AGE
58. SEX

    1. MALE
    2. FEMALE
60. OWNER NAME
61. OWNER PHONE
62. OWNER ADDRESS
64. RABIES VACCINATION?

    1. YES
    2. NO
65. WHERE GIVEN?
66. ANIMAL CURRENTLY ALIVE?

    1. YES
    2. NO
    3. UNKNOWN
68. ANIMAL'S CURRENT OR LAST KNOWN LOCATION*
72. BRIEFLY DESCRIBE THE CIRCUMSTANCES OF THE EXPOSURE:
74. FORM COMPLETED BY
75. PHONE
76. RELATIONSHIP TO VICTIM OR TITLE
Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field