INGHAM COUNTY



INGHAM COUNTY

ANIMAL BITE/EXPOSURE REPORT FORM

FAX: (517) 676-8380 PHONE: (517) 676-8370

Bite Victim Name: ___________________________________ Birthdate: ______________ Sex: M F

Home Address: _______________________________ City: _____________________ Zip: ___________

Home Phone: (_____)________________________ Alternate Phone: (____)___________________

Bite/Exposure Date: _____________________ Time of Day:____________________

Address Where Bite Occurred: _____________________________________________________________

Description of Bite/Exposure Incident:_______________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Provoked Bite: Yes or No Occult Exposure (Bat): Yes or No

Skin Penetration: Yes or No Location on body: _____________________________________

Treatment: Yes or No

Describe: Wound Care Antibiotics Td Booster RIG Rabies Vaccine

Treatment date: _____________

Facility/MD Name: ____________________________________ Phone: (____)___________________

Animal Type: Dog Cat Ferret Raccoon Skunk Woodchuck Bat Other:____________

Domestic Pet: Yes or No

Feral/Wild: Yes or No

Current Location of Animal: Destroyed Escaped/Released Confinement (home or vet office)

Owner’s Name: ________________________________________________________________________

Owner’s Address/City: __________________________________________________________________

Owner’s Phone: (_____)____________________ Alternate Phone: (_____)___________________

Rabies Vaccination Date(s): ______________________________________________________________

Rabies Tag #: _____________________

Veterinarian’s Name: _________________________________ Phone: (______)__________________

Bite Report to Law Enforcement: Yes or No Date Reported: ____________________________

Jurisdiction:_______________________________

Animal Specimen Sent for Testing: Yes or No Date Sent: _________________________________

Information Reported By: ___________________________________ Phone: (______)_____________

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