Form 4110 - Wslh Rabies Requisition Form

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Rabies Requisition Form (1/06)
FORM 4110
Submitter Information:
Reason for Rabies Testing
1.
Human Exposure (complete sections 2A, 3, 4, 5)
Animal Exposure (complete sections 2B, 3, 4, 5)
Other (complete sections 3, 4, 5)
specify _____________________________
(
Exposure Information
2.
complete section 2A for human exposure, 2B for animal exposure)
2A. Person Exposed
Exposure Date ____/____/____
(if more than one person exposed, complete back of form)
Physician (**required**)
Name ___________________________________________
Name _____________________________________________
Address _________________________________________
Clinic Name ________________________________________
City/State/Zip ____________________________________
Street Address _______________________________________
Date of Birth ________________ Age ________ Sex ____
City/State/Zip _______________________________________
Phone #: 1st (______)_________ 2nd (______)__________
Physician Phone (_____)______________
Type of Exposure:
Post Exposure Treatment:
Anatomical Site
□ Bite
□ Scratch
Vaccine □ Yes □ No
Date initiated ____________
□ Lick
□ Unknown
□ Yes □ No
HRIG
Date initiated ____________
□ Other __________________
None
2B. Animal Exposed
Exposure Date ____/____/___
(if more than one animal exposed, complete back of form)
Species
Age
□ Yes □ No □ Unkn
_______________________
Rabies Vaccination Current?
Owner (of exposed animal)
Type of Exposure:
Anatomical Site
□ Scratch
____________________________________
Bite
Address
□ Unknown
Ingestion
□ Other __________
________________________________
Lick
City/State/Zip
3, 4 & 5 Specimen Submission Information
3. Specimen Information
Number of animals submitted for testing: __________
□ Domestic-Owned
□ Domestic-Stray/Feral
□ Wild
□ Unknown
Species ________________________
□ Died □ Euthanized
Age
Date of Death
__________
___/___/___
□ Yes □ No □ Unkn
Rabies Vaccination Current?
Date of last vaccination: ___/___/___
Owner (of submitted animal) ___________________________
Vaccine lot ____________ manufacturer _______________
Animal vaccinated prior to last vaccine: □ Yes □ No
Address ____________________________________________
Animal Signs:
□ Aggressive
□ Ataxia
□ Convulsion
City/State/Zip _______________________________________
□ Depression
□ Disorientation □ Frothing
□ Howling/Bellowing
□ Nausea
□ Paralyzed
Phone # (_______) ________________________
□ Shallow Respiration
□ Other _________________
4. Veterinarian
_____________________________________
Name
Phone # (_____)________________________
Address _______________________________________
City/State/Zip ______________________________________
5. Local Health Department Jurisdiction
WSLH Use only

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