Form Il 482-0798 - Rabies Submission Form
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1
2RABIES SUBMISSION FORM
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 vaccine? YES
NO
N/A
Owner of suspect animal
Phone _________________________________
Address
County _________________________________
(
)of (
) total specimens submitted
NO EXPOSURE
Exposed Information
Date of Exposure _______/____/_________
Name, Address and Phone Number*
County Where
Type of Exposure
Site of Human
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__________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Is a fax report requested? YES
NO
Is a telephone report of negative test results requested? (for
emergency cases only please)
YES
NO
Please give telephone number here:
Please give fax number here: ____________________________
After hours telephone #: __________________________
Printed by Authority of the State of Illinois
P.O. # 555267 500
IL# 482-0798
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