Animal To Human Exposure Report
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1ANIMAL TO HUMAN EXPOSURE REPORT
CHESAPEAKE ANIMAL CONTROL
CHESAPEAKE HEALTH DEPT.
3807 COOK BLVD
748 N BATTLEFIELD BLVD
CHES VA
23323
CHES VA
23320
382-8080 FAX 485-7319
382-8672 FAX 382-8713
VICTIM
NAME: _________________________________________________________________
ADDRESS:_______________________________________________________________
TELEPHONE: (H) ____________ (W) ________________ CELL _________________
AGE: _________ RACE: _________ SEX:_________
PARENT/GUARDIAN: ______________________________________________________
DATE OF EXPOSURE:______TYPE OF EXPOSURE______PART OF BODY EXPOSED _____
ADDRESS WHERE EXPOSURE OCCURRED:_______________________________________
CIRCUMSTANCES SURROUNDING EXPOSURE:____________________________________
TYPE OF TREATMENT & PROVIDING FACILITY:________________________________
ANIMAL OWNER
WAS THIS ANIMAL BITTEN BY PROVEN OR SUSPECTED RABID ANIMAL? ___________
NAME: _________________________________________________________________
ADDRESS: ______________________________________________________________
TELEPHONE: (H) _______________ (W) ______________ CELL ________________
SPECIES _____ BREED _______ COLOR ________ NAME _________ SEX___ AGE___
RABIES# EXP __________ LIC# ___________ CHARGES ______ COURT DATE _____
LOCATION OF QUARANTINE: _______________________________________________
ANIMAL QUARANTINED ____________ANIMAL SUBMITTED FOR TESTING ___________
QUARANTINE PER: __________________ NO TEST PER _______________________
HEALTH DEPT.
HEALTH DEPT.
______________________________________________________________________
SIGNATURE OF PERSON COMPLETING REPORT
PRINT NAME
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