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
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.
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.
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.
Documentation of how bite occurred.
Description of Wound and Treatment provided
Additional Comments
Additional Documentation (Law Enforcement and non BHH Clinics)
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