VIR-16, Request for Rabies Examination
|New Jersey Department of Health |FOR LAB USE ONLY |
|Public Health Laboratories | |
|REQUEST FOR RABIES EXAMINATION | |
| |Lab Number |
| |Date Received |
| | |
|SECTION I - INFORMATION ON ANIMAL SUBMITTED |
|1. Type of Animal (e.g., dog, cat, raccoon, etc.) |2. Was Animal: |3. Date of Death |
| |Pet Stray Wild | |
|4. Cause of Death |5. Is/was pet vaccinated for Rabies? |
| |Yes No |
|Euthanized Found Dead Other: | | | |
| | |
|6. Animal Behavior Before Death (Check all that apply) |
|Apparently Normal Lethargic or In Coma Wobbly Gait Not Afraid of Humans or Domestic Animals |
|Appeared Sick Drooling Saliva Paralysis Other (Explain): | | |
|Aggressive Overly Friendly Wild Animal Out in Daylight Unknown |
|7. Owner of Animal/Residence of Specimen Origin: |
|Name: | | |Tel. No.: |( ) | |Munic.: | | |
|Mailing Address: | | |
| |
|8. Delivered By: |
|Name: | | |Tel. No.: |( ) | |
|Mailing Address: | | |
| |
|9. Health Officer: |
|Name: | | |Fax No.: |( ) | |
|Mailing Address: | | |
| |
|10. Attending Veterinarian (If applicable): |
|Name: | | |Tel. No.: |( ) | |
|Mailing Address: | | |
| |
|11. Animal Control Officer (If applicable): |
|Name: | | |Tel. No.: |( ) | |
|Mailing Address: | | |
| |
|SECTION II - HUMAN EXPOSURE INFORMATION |
|12. Were any people bitten or exposed to this animal? |
|Yes-Bitten Yes-Exposed No |
|13. County/Municipality Where Exposure Occurred |14. Date of Exposure |
| | |
|15. Persons Bitten By or Exposed To Animal |
|Name: | | |Tel. No.: |( ) | |Munic.: | | |
|Mailing Address: | | |
| |
|16. How did the exposure to this animal occur? |17. Has emergency rabies treatment of the |
| |exposed person been started? |
| |Yes No Unknown |
|SECTION III - ANIMAL EXPOSURE INFORMATION |
|18. Were any other animals bitten or exposed to this animal? |19. Type of Animal Exposed |20. Date Animal Exposed |
|Yes-Bitten Yes-Exposed No | | |
|21. Has exposed animal been vaccinated for rabies? |22. How did the exposure occur? |
|Yes No | |
|23. Owner of Animal Exposed: |
|Name: | | |Tel. No.: |( ) | |Munic.: | | |
|Mailing Address: | | |
| |
VIR-16
APR 16
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