Report an Animal Bite/Exposure Form

Detail of Reporting Organizations

Report Date(Required)

Reported by(Required)

Bluewater Health – CEE

Bluewater Health – Norman

Other

If other, please specify:(Required)

Details of Attending Health Care Provider

Name (First and Last):(Required)

Phone(Required)

Email(Required)

Additional Contact Information

Detail of Person Bitten/Exposed

Name:(Required)

Date of Birth:

Age:

Sex:

Weight:

Previous Rabies Treatment

Previous Rabies Treatment Dates

Phone 1:(Required)

Phone 2:

Address(Required)

Street Address City Province Postal Code

Primary Care Provider Name

Primary Care Provider Phone Number

Bite/Exposure Details

Wound Location(Required)

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 Details

Incident Date(Required)

Incident Time

Description of incident (Please provide details including, why /where/ how?)(Required)

Animal Behaviour

Normal

Abnormal

Attack Provoked

Yes

Animal Information

Please 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 Age

Animal Colour

Animal Size

Animal Vaccination Status

Vaccinated

Unvaccinated

Vaccination status unknown

Animal Vaccination Date(Required)

Veterinarian Name:

Veterinarian Phone Number:

Owner Information

Please complete as much as possible

Are the victim and owner the same person?

Yes

Name of Owner:

Name of Owner (Additional):

Phone (Cell):

Phone (Home):

Address

Street Address Address Line 2 City 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.