Utah Screwworm Suspect Report Form
For suspected domestic animal cases only. Please contact your local health department for human disease concerns. Please submit wildlife cases through the form found at https://form.jotform.com/261335276473056.
Reporter Information
Reporter Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reporter Email
*
example@example.com
Reporter Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Owner Information
Owner Name
*
First Name
Last Name
Owner Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner Email
example@example.com
Owner Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Animal Information
Species
*
Animal Status (at time of reporting)
*
Dead
Alive
Location of Animal
*
At Owner Address
Different Address
Enter Location on Map
Address of Animal (if different from owner)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Detected Location
Picture of Wound
*
Browse Files
Drag and drop files here
Choose a file
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of
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Wound Description (Smell, and length of time)
*
Were flies present?
*
Yes
No
How many maggots were pulled for sampling from wound?
*
Recent Travel History For Animal and Owner
*
Other Animals and Number
*
Submit
Should be Empty: