Fillable Human Bite Report Form printable pdf download

HUMAN BITE REPORT FORM

ANY HUMAN EXPOSURE TO A POTENTIALLY RABID ANIMAL

FLATHEAD CITY-COUNTY HEALTH DEPARTMENT, MONTANA

FAX REPORT TO 406-751-8127

PART 1 – Completed by HealthCare Provider, Not Patient

Patient’s Name: ___________________________________________________ Age: ______________ ☐ Male ☐Female

Address: ____________________________________________________________________________________________________

Phone: __________________________________ Parent/Guardian (if <18): _____________________________________________

Bite/Exposure Information:

Date of Bite/Exposure: _________________________ Time: _________________ AM PM (circle one)

Part of Body Bitten: ________________________________________________ Skin Broken: ☐Yes

☐No

☐Yes

☐No _____________________________________________________ Date: __________________

Treatment Given:

Physician: _________________________________________________ Phone: ____________________________

Name of Reporting Clinic/ED/Urgent Care: _______________________________________________________________

☐ Dog ☐ Cat

☐Other ________________________

Description of Animal:

Address/Location of Incident: ___________________________________________________________________________________

How Bite/Exposure Occurred (if known):___________________________________________________________________________

____________________________________________________________________________________________________________

PART 2 – HEALTH DEPARTMENT OFFICE USE ONLY

Animal Control Officer: _________________________________

CR#: ______________________

Animal Owner’s Name (if known): _____________________________________________ Phone: ___________________________

Address: __________________________________________________________________________________________________

Animal Information:

Animal Name: ____________________ Breed: _____________________ Color/s: __________________

☐M

☐F

License No.: ______________________ Vaccinated: ☐Yes ☐No ☐Unknown

Age: ________________

Vaccination Cert. No.: ____________________ Vaccination Date: ___________________

Veterinarian: _________________________________________ Phone: __________________________

Provoked Bite: ☐Yes ☐ No Prior Bites Reported: ☐Yes ☐No

Animal Disposition:

☐Animal Cannot Be Located Date: _________________

Badge: ________________________

☐Animal Died/Euthanized Date: ___________________ Badge: ________________________

☐Animal Quarantined for 10 days – ☐Animal Shelter ☐Vet ☐Home

Start Date: _________________ Badge: _____________

☐Animal Specimen Shipped to Laboratory Date: _______________

Badge: ___________________

F.R.A. Test: ☐ Yes

☐ No

Test Results: ☐Positive ☐ Negative

☐Unsuitable

Date: _______________

Victim Notified: ☐Yes ☐ No

Date: __________________ Initials: __________________

Follow-Up:

☐Animal examined at end of quarantine and is healthy Date:__________________ Badge:________________

Notes: ______________________________________________________________________________________________________

____________________________________________________________________________________________________________

Human Bite Report Form

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