Animal Incident Report Bureau Of Environmental Health Services
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1Animal Incident Report
Bureau of Environmental Health Services
Date Incident Reported: ____________________________ Time Incident Reported: ______________________AM/PM
Person Reporting Incident: __________________________________________________________________________
Phone: __________________________ Ext: ________ ER/Medical Office: ___________________________________
DHEC Person Contacted: ____________________________ DHEC Number/Fax Contacted: _____________________
Victim Information
o Human o Animal
Date/Time of Bite/Exposure: ___________________ AM/PM County Where Bite/Exposure Occurred: _______________
Victim’s Name: _______________________________ DOB: ___________________
Sex: M
F
Phone (H): _________________________ (W): ____________________ Ext: ________ (C): _____________________
Physician: _______________________________ Office Phone: ____________________________ Ext: ____________
Parent/Guardian (If Minor): __________________________________________________________________________
Address (If Not a Street Address, Give Directions): _______________________________________________________
__________________________________ City: ___________________________ State: ________ Zip:_____________
Describe Circumstances of Bite/Exposure; Severity and Location of Wound: ___________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Animal Information (
This information will assist DHEC in making sure the animal is quarantined or tested for rabies.)
Type of Animal: __________Owned: ____ Not Owned: _____ Breed: ___________Sex: ____Size: _____Color: _______
Owner _______________________________________________ Pet’s Name: ________________________________
Phone (H): _________________________ (W): ____________________ Ext: ________ (C): _____________________
Address (If Not a Street Address, Give Directions): _______________________________________________________
__________________________________ City: ___________________________ State: ________ Zip:_____________
Location and Condition of Animal at Time of Incident: ______________________________________________________
Current Location of Animal: __________________________________________________________________________
**********************************************************************************************************************************************
Submitting Instructions: Please fax this form to the appropriate Environmental Health Services
office for the county where the bite/exposure occurred.
SCDHEC, UST Management Division, 2600 Bull Street, Columbia, SC 29201, PHONE (803)898-7957 FAX (803) 896-6245
DHEC 1799 (05/2015)
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
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