Health Care Professionals Report an Animal Bite/Exposure Form Report an Animal Bite/Exposure FormDetail of Reporting OrganizationsReport Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reported by(Required) Bluewater Health – CEE Bluewater Health – Norman Other If other, please specify:(Required) Details of Attending Health Care ProviderName (First and Last):(Required) Phone(Required)Email(Required) Additional Contact Information Detail of Person Bitten/ExposedName:(Required) Date of Birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:Sex: Weight:Previous Rabies TreatmentYesNoPrevious Rabies Treatment DatesMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone 1:(Required)Phone 2:Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Primary Care Provider Name Primary Care Provider Phone NumberBite/Exposure DetailsWound Location(Required) Head Left Arm Right Arm Left Hand Right Hand Left Leg Right Leg Left Foot Right Foot Other Type of Wound(Required) Bite Scratch Broken Skin (Yes) Broken Skin (No) Other Treatment(Required) Tetanus Shot Stitches Cleansing/Bandaging Other If other location, please specify.(Required) If other type of wound, please specify.(Required) If other treatment, please specify.(Required) Incident DetailsIncident Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Incident Time Hours : Minutes AM PM AM/PM Description of incident (Please provide details including, why /where/ how?)(Required)Animal Behaviour Normal Abnormal Attack Provoked Yes No Animal InformationPlease provide as much detail as possible.Species of Animal(Required) Dog Cat Bat Other The Animal is: Owned Stray Wild If other, please specify:(Required) Animal Name Animal Breed Animal AgeAnimal Colour Animal Size Animal Vaccination Status Vaccinated Unvaccinated Vaccination status unknown Animal Vaccination Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Veterinarian Name: Veterinarian Phone Number:Owner InformationPlease complete as much as possible Are the victim and owner the same person? No Yes Name of Owner: Name of Owner (Additional): Phone (Cell):Phone (Home):Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Please provide any additional comments:Personal information on this form is collected under the authority of the Health Protection & Promotion Act, R.S.O. 1990, C.H-7 for the purposes of initiating a rabies exposure investigation by Lambton Public Health which includes assessment, management, treatment, and reporting purposes. Where rabies post exposure prophylaxis (PEP) has been recommended or there is a confirmed human rabies case following investigation, information from this form will be entered into a provincial database called the Integrated Public Health Information System (iPHIS). Information provided may be shared with relevant third parties applicable to an investigation. Questions related to the collection, use and disclosure of this information may be directed to Lambton Public Health at 519-383-8331 or toll free 1-800-667-1839.