Rabies Submission Form

RABIES SUBMISSION FORM

Submitter Last Name

Submitter First Name

Address

City

State

Zip

Phone

ANIMAL LOCATION: Location of Animal or Exposure

Address

City

State

Zip

SAMPLES

Consecutive Sample ID#'s

Whole Body

Head

RABIES VACCINATIONS (CHECK ONE)

Vaccinated/Date

Not Vaccinated

Unknown

DISPOSITION OF REMAINS (REQUIRED)

No remains returned

Private Cremation

PATIENT INFORMATION

Species

Breed

	#	Animal ID	Age	Gender	Weight	Date of Death	Cause of Death
	1						Euthanized Natural Death Submitted Alive

Clinical observations/comments:

HUMAN EXPOSURE HISTORY - PROVIDE ALL DATA REQUESTED

UNKNOWN - not known at this time if human exposure is associated with this case. NO - human exposure is NOT associated with this case. YES - human exposure is associated with this case.

Number of potential human exposures

Name of exposed

Address

State

City

Zip

Day Phone

Cell Phone

Date of exposure

Type of exposure

Site of exposure

Additional comments

Physician

Clinic

Address

Physician Phone

Physician FAX

State

City

Zip

If this is a qualifying case, would you like to run ASAP as an emergency and be assessed an additional fee of $100?

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If you are experiencing difficulty or need additional help, please contact the ISU VDL at 515-294-1950.