Beaverhead County Animal Bite Reporting Form
*This is a HIPPA compliant form for reporting to Beaverhead County Public Health. Fields with red asterisk are required
Please upload rabies vaccination certificate and quarantine form at the bottom of this page if you have it. Thank you!
Uploads may also include photos and other pertinent documentation.
Date of Report
*
-
Month
-
Day
Year
Date
Who is Reporting
*
Healthcare Facility
Citizen
Law Enforcement
Veterinary Office
Other
Healthcare Facility
*
Please Select
Barrett Hospital ER
Barrett Hospital Clinic
Beaverhead Urgent Care
Blacktail Medical Clinic
Other
Name of Facility
Name of Reporter
First Name
Last Name
Reporter Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Bite
*
-
Month
-
Day
Year
Date
Time of Bite
Hour Minutes
AM
PM
AM/PM Option
Location where bite occurred
*
Has law enforcement been notified?
*
Yes
No
Reason Law Enforcement not notified
*
Was Rabies Post Exposure Prophylaxis Initiated?
*
No
Yes
Was TdaP administered?
*
Patient up to date
Yes
No
Victim Name
*
First Name
Last Name
Victim DOB
*
-
Month
-
Day
Year
Date
Victim Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Victim Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Animal
*
Domestic
Wild
Select Wild Species
*
Bat
Skunk
Fox
Wolf hybrid
Raccoon
Rodent
Other
Select Domestic Species
*
Dog
Cat
Ferret
Horse
Cow
Other
Disposition of Animal
Owned by victim
Owned by other
Stray/ feral
Location unknown
Alive and in Quarantine
Euthanized
Waiting to be tested
Rabies Vaccination Status
*
Up to date and documented
Not Vaccinated
Unknown
Date of last Rabies Vaccination
-
Month
-
Day
Year
Date
Name of Owner (if different than victim)
First Name
Last Name
Owner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Documentation of how bite occurred.
Description of Wound and Treatment provided
Additional Comments
Additional Documentation (Rabies certificate, images, quarantine agreement)
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