Animal Encounter Report Form - West Virginia Bureau Of Public Health printable pdf download

Animal Encounter Report Form

SG-58

FOR HEALTHCARE PROVIDER/FACILITY ATTENDING TO ANIMAL BITE PATIENT

PAGE 1

REV. 10/12

Note to Providers: Complete as much information as possible on page 1 of this form. Fax this report to the local health

department immediately.

PATIENT DEMOGRAPHICS

Name (last, first): __________________________________________________________

Birth date: __ / __ / ____

Age: _____

Male Female

Unk

Address (mailing): _________________________________________________________

Sex:

Not Hispanic or Latino

Address (physical):_________________________________________________________

Ethnicity:

Hispanic or Latino

Unk

City/State/Zip:

__________________________________________________________

White Black/Afr. Amer.

Phone (home):

________________

Phone (work/cell) :

___________________

Race:

Asian Am. Ind/AK Native

Parent/Guardian

Spouse

Other

Alternate contact:

(Mark all

Native HI/Other PI

 Unk

Name: __________________________________________ Phone: ________________

that apply)

PROVIDER INFORMATION

Physician: ________________________________________________ Phone: ______________ Fax: _______________

Facility: __________________________________________________ Address: __________________________________________

City/State/Zip: _____________________________________________ Date reported to health department: ___/___/_____

BITE/EXPOSURE INFORMATION

Exposure date: __ / __ / ____

Circumstances of Bite/Exposure

Y N U

Exposure Type

   Bite or scratch caused a break in the skin

Y N U

   Bite

Head/neck/face Hand

If yes, where on body (mark all that apply):

   Scratch

Leg

Torso/chest/back

Arm

Foot

   Saliva/CNS tissue contact with fresh* wound

   Exposure was provoked

   Saliva/CNS tissue contact with mucous membrane

   Animal was behaving abnormally

   Bat exposure with no definite bite or scratch

   Other (Describe:______________________)

Fresh wound=a wound that has bled within past 24 hours

CLINICAL INFORMATION

Hospitalization

Treatment

Y N U

   Patient hospitalized for this exposure

   Patient wound cleaned

   Patient started rabies PEP series

If yes, hospital name: ________________________________

Admit date: __ / __ / ____

Discharge date: __ / __ / ____

If yes, name of facility initiating PEP series:

_______________________________________________

If yes, did patient complete series?: Yes No Unknown

Death

Y N U

Please document known vaccination dates below:

   Patient died due to this exposure

#1: __ /__ /____ #2: __ /__ /____ #3: __ /__ /____ #4: __ /__ /____

   Patient received human rabies immune globulin (RIG)

If yes, date of death: __ / __ / _____

If yes, RIG date: __ / __ / ____

Vaccination History

Y N U

   Patient previously received rabies vaccine prior to this

exposure

If yes, date of previous vaccination: ___ / ___ / ______

ANIMAL INFORMATION

Species Causing Exposure

Ownership status of animal:

(mark all that apply)

 Bat

 Fox

 Raccoon

 Owned (pet, livestock, etc.)

 Cat or kitten

 Goat

 Rodent

Owner Name: _______________________________________________

 Cow

 Horse

 Sheep

Owner Address: ______________________________________________

 Coyote

 Monkey

 Skunk

City/State/Zip

: ____________________________________________________

 Dog or puppy

 Pig

 OTHER (list):

Owner Phone: ________________

 Ferret

 Rabbit

 Non-owned (wild, stray, etc.)

______________

 Unknown

Total number of animals involved in encounter: ______

ADDITIONAL NOTES:

Y=Yes N=No U=Unknown NA=Not applicable

Division of Infectious Disease Epidemiology

rev 10-12-12

Animal Encounter Report Form - West Virginia Bureau Of Public Health

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