Rabies Test Submission Report - Ohio Department Of Health
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1
2Ohio Department of Health Laboratories
Internal Rabies Number
LITS NUMBER
Rabies Test Submission Report
ODH LAB USE ONLY
ODH LAB USE ONLY
Animal Information
(to be completed by submitter)
Species:
Predominant Breed:
Sex
Age
Male
Bat Cat Dog Horse Raccoon Other (indicate)
Female
___________
Reason for Test: (Check the primary reason)
Human Exposure
Odd Behavior/Sick/Wounded
Found Dead
Pet/Domestic Animal Exposure
Nuisance/Otherwise Healthy
Roadkill
Date of Collection (MM/DD/YYYY)
/
/
Owner’s address or location where found:
County
City
State
ZIP
Latitude (in decimal degrees)
Longitude (in decimal degrees)
.
.
Case Administration
(to be completed by submitter)
Human exposures?
# of non-bite exposures
Yes
No
Unknown
# of persons bitten
Post-exposure prophylaxis?
# of persons treated for rabies
Animal exposures
Yes No
Yes
No Unknown
Name of
person exposed or
pet owner (Check One)
Submitter of Animal:
Last Name
First Name
Telephone
_
_
Local Health Department Information
Submitter Address for Reporting Results
(to be completed by submitter)
Name
Local Health Department Name
Address
City
State
ZIP
Contact person
Phone
Fax
Telephone
_
_
Bill To:
(see submission guidelines for non-exempt testing)
Name
Comments
Address
City
State
ZIP
Phone
For Lab Use Only
Date Received
Billing
Specimen Type
Exempt
Fee Due
Brain
Skull Impression
Specimen Condition
Decomposed
Mutilated
Satisfactory
Unsatisfactory/missing
Test Name: Direct Fluorescent Antibody
DFA Result
Positive
Negative
Date Reported
Person contacted with result
Date of Call
Initials
HEA 2539 (Rev. 10/12)
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