Utah Screwworm Suspect Report Form
For suspected animal cases only. Please contact your local health department for human disease concerns.
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
Take Photo
Wound Description (Smell, Length of time, and Presents of Flies)
*
Recent Travel History For Animal and Owner
Other Animals and Number
*
Submit
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