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Dd Form 2341 - Report Of Animal Bite - Potential Rabies Exposure

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SEQUENCE NUMBER

REPORT OF ANIMAL BITE - POTENTIAL RABIES EXPOSURE

(Please read Privacy Act Statement before completing this form.)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Section 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8013, Secretary of the Air Force;

DoD Directive 6400.4, DoD Veterinary Services Program; AR 4-905, SECNAVIST 6401.1B, AFI 48-131, Veterinary Health Services; and E.O. 9397

(SSN).

PRINCIPAL PURPOSE(S): Used by medical authorities to record the history, examination, and treatment of a person who has possibly been exposed

to rabies; and to record the follow-up medical care provided to the patient. Used by veterinarians to locate the animal, record examination,

observations, and disposition results, and possible laboratory findings for the animal.

ROUTINE USE(S): The DoD "Blanket Routine Uses" that appear at the beginning of the Army's compilation of systems of records apply to this

system. Information may be disclosed to aid in preventive health and communicable disease control programs and report medical conditions to

Federal, state and local agencies, required by law.

DISCLOSURE: Voluntary. However, failure to provide all the requested information may result in the improper treatment and care being administered

to the patient.

1. FROM

2. THRU

3. TO

(Medical Treatment Facility)

(Veterinary Service Activity)

(Chief, Preventive Medicine)

PART I - ANIMAL BITE HISTORY

(To be completed by Emergency Room or Primary Care Interviewer)

4. DESCRIPTION OF ANIMAL

5. TIME OF ATTACK

a. TYPE

b. BREED

c. SIZE

d. COLOR

e. SEX

a. DATE

b. HOUR

(Dog, cat, etc.)

(YYYYMMDD)

6. PRESENT LOCATION OF ANIMAL OR GEOGRAPHIC ADDRESS WHERE ATTACKED

ON POST

OFF POST

7. CIRCUMSTANCES LEADING TO BITE/SCRATCH INCIDENT

8. APPARENT HEALTH OF ANIMAL

(Unusual Behavior)

9. ANIMAL OWNER

a. NAME (Last, First, Middle Initial)

c. PHONE NUMBER

d. ADDRESS

(Street, City, State, Zip Code)

b. STATUS

(X one)

(Include Area Code)

MILITARY

CIVILIAN

10. RABIES VACCINATION

a. VACCINATION STATUS OF ANIMAL

b. YEAR ANIMAL

c. TYPE VACCINE

VACCINATED

(If known)

11. FORM PREPARED BY

a. NAME

b. TITLE

(Last, First, Middle Initial)

c. SIGNATURE

d. DEPARTMENT/SERVICE/CLINIC

e. DATE PREPARED

(YYYYMMDD)

12. PATIENT'S IDENTIFICATION

(ID impression, if available.) (For typed or written entries give name (Last, First, Middle Initial); pay grade; SSN; unit; duty and home

telephone numbers; date; hospital or medical facility.)

Page 1 of 3 Pages

DD FORM 2341, OCT 2007

PREVIOUS EDITION IS OBSOLETE.

Adobe Professional 8.0

Dd Form 2341 - Report Of Animal Bite - Potential Rabies Exposure

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