Fillable Dd Form 2623 - Animal Home Quarantine printable pdf download

Dd Form 2623 - Animal Home Quarantine

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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.

PRINCIPAL PURPOSE(S):

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

quarantine period.

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.

1. AGREEMENT

, 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

Facility.

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

)

between

and

hours on

and

for

official release from quarantine subsequent to final examination results.

2. OWNER

a. SIGNATURE

b. DATE SIGNED

c. UNIT

d. ADDRESS OF QUARANTINE LOCATION

e. TELEPHONE NUMBER

3. VETERINARY STAFF MEMBER

DD FORM 2623, JUN 2013

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Dd Form 2623 - Animal Home Quarantine

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