Dd Form 2620 - Request For And Report Of Laboratory Examination For Rabies
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1REQUEST FOR AND REPORT OF LABORATORY EXAMINATION FOR RABIES
PRIVACY ACT STATEMENT
Title 10, United States Code, Sections 3013, 5013, and 8013.
AUTHORITY:
To provide for documentation of the results of laboratory examinations of a deceased animal for rabies.
PRINCIPAL PURPOSE(S):
The results of the examinations are used to determine the proper medical management of patients potentially
ROUTINE USE(S):
exposed to rabies because of a bite/scratch inflicted by the animal described and belonging to the owner named.
The information may also be used to: aid in preventive health and communicable disease control programs; report
medical conditions required by law to Federal, state, and local agencies; compile statistical data; conduct research;
teach; assist in law enforcement, to include investigations and litigation; and evaluate the care provided.
Voluntary; but if information is not provided, all pertinent and relevant information regarding the medical history of
the animal cannot be evaluated. Comprehensive medical care to the individual potentially exposed to rabies may
DISCLOSURE:
not be possible, but care will not be denied.
2.a. FROM
1. TO
b. TELEPHONE NUMBERS (Incl. Area Code)
(1) DUTY
(2) AFTER HOURS
DSN
DSN
COMMERCIAL
COMMERCIAL
SECTION I - REQUEST FOR TEST
PART A - IDENTIFICATION
3. OWNER OF ANIMAL (Last Name, First, Middle Initial)
4. ANIMAL
a. SPECIES
b. PET OR STRAY
c. AGE
PART B - SYMPTOMATOLOGY
(Past 3 to 5 days) (X all blocks that apply)
5. COULD ANIMAL CLOSE MOUTH?
6. SALIVATING?
THIN/WATERY
7. ABLE TO DRINK WATER?
UNKNOWN
NO
YES
NO
YES
THICK/ROPY
UNKNOWN
NO
YES
8. LOSS OF APPETITE?
9. EATING UNUSUAL THINGS?
10. DIFFICULTY IN SWALLOWING?
UNKNOWN
NO
YES
UNKNOWN
NO
YES
UNKNOWN
NO
YES
13. DATE FIRST NOTICED SICK
11. NERVOUS OR UNUSUAL BEHAVIOR?
12. PARALYSIS OF ANY KIND?
UNKNOWN
NO
YES
UNKNOWN
NO
YES
14. DATE OF DEATH
15. MANNER OF DEATH
DIED
EUTHANIZED
PART C - HISTORY
b. DATE
c. TYPE OF VACCINE
16. HAD ANIMAL BEEN VACCINATED AGAINST RABIES?
a. (X one)
NO
YES
PART D - HUMAN EXPOSURES
NAME
ADDRESS
TELEPHONE NUMBER
BITTEN?
SALIVA?
17.
(Last, First, Middle Initial)
(Street, City, State, Zip Code)
(Include Area Code)
(Yes/No)
(Yes/No)
a.
b.
c.
d.
e.
18. CLINICAL DIAGNOSIS, NECROPSY FINDINGS, AND REMARKS
19. VETERINARIAN a. TYPED NAME
b. GRADE
c. TITLE
d. SIGNATURE
e. DATE
(Last, First, Middle Initial)
SECTION II - LABORATORY REPORT OF RABIES EXAMINATION
20. DATE SPECIMEN RECEIVED
21. CONDITION
22. LAB ACCESSION NUMBER
23. FLUORESCENT ANTIBODY RESULTS 24.RESULTS TELEPHONED a. TO b. DATE
c. HOUR
d. BY
25. CELL CULTURE RESULTS
26. FINAL LABORATORY DIAGNOSIS
27. SUBMITTED BY a. TYPED NAME
b. GRADE
c. TITLE
d. SIGNATURE
e. DATE
(Last, First, Middle Initial)
DD Form 2620, JUN 92
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