ANIMAL HOME QUARANTINE
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136; DoD Directive 5136.01; Army Regulation 40-905; SECNAVINST 6401-1B; AFI 48-131.
To document that the owner of an animal possibly exposed to rabies is aware of their
obligations for home quarantine of the animal and to allow officials to check on the animal and owner during the
ROUTINE USE(S): The inform
ation may be used to aid in preventive health and communicable diesease control
programs, report medical conditions required by law to Federal, state and local agencies. The DoD Blanket Routine
uses found at may also apply.
DISCLOSURE: Voluntary. However, if you fail to provide the requested information you may not be able to
quarantine your pet at home.
, being the owner of an animal possibly exposed
to rabies, do agree to the following as a prerequisite for quarantining my animal at home:
a. That I will keep this animal either indoors or in an enclosed, excluded area at all times during the quarantine period.
b. That I will not allow this animal to come in contact with other animals or anyone other than the members
of my immediate family.
c. That I will report any unusual change in behavior or any sudden symptoms to the Veterinary Treatment
d. That in the event of the death of the animal, I will notify the Veterinary Treatment Facility at:
at once. (On weekends and holidays, call
and ask for the veterinary staff member on call.)
e. That I will bring said animal to the Veterinary Treatment Facility (Building Number
official release from quarantine subsequent to final examination results.
b. DATE SIGNED
d. ADDRESS OF QUARANTINE LOCATION
e. TELEPHONE NUMBER
3. VETERINARY STAFF MEMBER
DD FORM 2623, JUN 2013
Adobe Professional X