Form Dhhs 1614 - Rabies Examination - N.c. Department Of Health And Human Services printable pdf download

[1] Federal Tax No.: ______________________________________

DO NOT WRITE IN

N.C. Department of Health and Human Services

THIS SPACE

State Laboratory of Public Health

4312 District Drive • P.O. Box 28047

LABORATORY NUMBER

Send Report To (Facility Name/Address):

Raleigh, North Carolina 27611-8047

____________________________________________________

PLEASE GIVE ALL

INFORMATION REQUESTED

________________________________ Zip Code ___________

Rabies Examination

[2] Contact Name: _______________________________________

Telephone # from 8 AM until 4 PM (

)

[4] Species of Animal: ____________________________________

Telephone # after 4 PM and on weekends (

)

Breed/Color: ______________ Specimen ID#: ______________

Fax # (

)

[3] Where was the animal found:

If Domestic Animal:  Owned

 Stray

 Feral

County: ___________________ GPS Location: _____________

Ever vaccinated?  Yes (include all dates) ________________

 No

Address: ____________________________________________

[5] Date of Death: ______________ Date Shipped: _____________

City: ______________________ State: _____ Zip: __________

Signs of Disease:

[6]

 Animal exhibited signs of rabies:  neurological

 convulsions

 unable to eat or drink

 excessive salivation

 unusually vicious  Other ______________________________ Date of Onset: _____________________________________

 Wild animal showing abnormal behavior

 Bat found in home or occupied dwelling Bats previously in building?

 No  Yes (dates) _______________________________

 Animal was not known to have exhibited signs of disease

 Other ______________________________________________________________________________________________________

Persons Exposed to This Animal & Nature of Exposure / Owner of Domestic Animals Exposed to This Animal

[7]

Name

Date of Exposure

Type of Exposure

 bite  scratch  handling  in dwelling with bat

 other ____________________________________________

 bite  scratch  handling  in dwelling with bat

 other ____________________________________________

 bite  scratch  handling  in dwelling with bat

 other ____________________________________________

• All positive, indeterminate, unsatisfactory, or test not performed results will be reported by telephone to the contact person listed

above. This individual will be responsible for arranging treatment of this/these patient(s) if this should be necessary. You MUST include

telephone numbers with area code where this individual can be reached during working hours, after working hours and on weekends.

• All negative results will be sent via courier or U.S. mail to submitter. All rabies results are also available on our website at

FOR LABORATORY USE ONLY

FLUORESCENT ANTIBODY TEST RESULTS

Condition Upon Receipt

 cold  ambient  frozen

 Negative

 Positive

 Unsatisfactory

 Decomposed

 Brain Destroyed

 Test Not Performed

 Indeterminate

Results telephoned: __________________ _____________ ________________________________ _____________________________

date

time

reported to

reported by

DHHS 1614 (Revised 4/2015)

Laboratory Services (Review 4/2018)

SEE REVERSE SIDE FOR INSTRUCTIONS AND FURTHER INFORMATION

Form Dhhs 1614 - Rabies Examination - N.c. Department Of Health And Human Services

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