Bite Report Form
Please submit this form to report a human exposure to a potentially rabid animal. If you have any questions about this form, contact the Flathead City-County Health Department Communicable Disease Program at 406-751-8117.
Select the type of facility you are reporting from
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Medical Facility
Veterinary Facility
Self-Report
Name of Reporting Facility (If you are self reporting, write 'Self Report')
*
Name of Person Reporting Exposure
*
First Name
Last Name
Phone Number of Person Reporting Exposure
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is this report being submitted for?
*
A human bitten by a domesticated pet (dog, cat, ferret)
A human bitten by a stray dog or cat
A human bitten by a wild animal or bat (high risk animals include raccoons, foxes, skunks, and bats)
Other
Patient Information
Patient Name
*
First Name
Last Name
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Exposure Information
Date of Exposure
*
-
Month
-
Day
Year
Date
Time of Exposure
*
Type of injury (select all that apply)
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Bite
Scratch
Saliva in mucous membrane
Other
Where is the injury located on the body
*
Example: Bite mark on left arm
Was the skin broken?
*
Yes
No
Describe the incident
*
Did the incident occur at the patient's home address or at a different location?
*
Incident occurred at home
Incident occurred at a different location
Address of the location where the incident occurred
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Animal Information
Select the species of animal involved in the incident
*
Dog
Cat
Bat
Ferret
Other
Is this animal domesticated or wild?
*
Domestic
Wild
Name of animal
Description of animal
*
Select the current rabies vaccination status of the animal
*
Animal is up-to-date on rabies vaccination
Animal has received rabies vaccination in the past, but is not up-to-date
Animal has never been vaccinated for rabies
Unknown
Other
Provide the last rabies vaccination date of the animal
Animal Owner Information
Is the bite victim the owner of the animal?
*
Yes
No
The animal is wild or stray and does not have an owner
Name of Owner
First Name
Last Name
Address of Owner
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Owner
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Contact for Owner
INFORMATION FOR VICTIM NOTICE: In accordance with the Administrative Rules of Montana (ARM) 37.114.571 and 32.3.1201, all animals bites must be reported to the local health department immediately so an investigation can commence. The local health department investigates animal bites in an effort to prevent rabies (a communicable disease) from being transmitted to people. You will be contacted by a FCCHD staff member in order for more information regarding the bite to be collected. If you were bitten by a dog or cat, an attempt will be made to locate that animal to verify rabies vaccination status. The animal will have to be observed for 10 days after the bite. On day 10 that animal will be released from observation if there are no signs or symptoms of illness. You will be updated during the investigation and after the 10 day post-bite health check. If you have questions, please contact FCCHD Communicable Disease 406-751-8117.
*
I have read and agree to the above statement.
Would you like to receive a copy of your submitted report?
*
Yes
No
Email
example@example.com
Submit
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