Ioci 16-121 Rabies Submission Form - Illinois Department Of Public Health
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1
2Rabies Submission Form
State of Illinois
Illinois Department of Public Health
Laboratory Number ___________________________
Date Received _______________________________
1. Use one form for each specimen tested.
Time Received _______________________________
2. Complete all the information requested.
Method of Transport___________________________
3. Label each specimen to correspond with the submission form.
For laboratory use only
4. Please read the submitting instructions given on the reverse side.
Animal Information
Animal species __________________________________ Breed ___________________________________________
Description: Color________________________________ Size_____________________________________________
Died
Was killed
Date of collection _____________
Did the animal exhibit signs of rabies? YES
NO
Did the domestic animal have a current rabies vaccination? YES
NO
N/A
Owner of suspect animal ___________________________________________________ Phone___________________
Address ________________________________________________________ County __________________________
(
) of (
) total specimens submitted
NO EXPOSURE
Exposed Information
Date of Exposure _____________
County Where
Site of Human
Name, Address and Phone Number*
Type of Exposure
Exposure Occurred
Exposure
*(Phone number required if exposure has occurred.)
Human
Bite
Scratch
Animal
Other
Human
Bite
Scratch
Animal
Other
Human
Bite
Scratch
Animal
Other
Human
Bite
Scratch
Animal
Other
Submitting Agency Information
Submitted by ______________________________________________________________________________________
Address ______________________________________________________________ Phone ____________________
Send Report to_____________________________________________________________________________________
Address ______________________________________________________________ Phone ____________________
Brief Description of Exposure/Comments (Please include where the animal was found)
Is a telephone report of negative test results requested?
Is a fax report requested?
YES
NO
(for emergency cases only please) YES
NO
Please give fax number here: _______________________
Please give telephone number here: __________________
After hours telephone number: ____________________
Printed by Authority of the State of Illinois
IL# 482-0798
IOCI 16-121
P.O. #555254
500M
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