EXPOSURE REPORTING - ANIMAL BITE FORM

EXPOSURE REPORTING - ANIMAL BITE FORM

State and local laws require all bites be reported

Reporting Party/Facility -

Today's Date -

MonthDayYear
Date

Patient Information
Patient Name -

First NameLast Name
Phone Number -

Area CodePhone Number
Address -

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional notes or contact information -

Owner Information

Please fill out the following fields if owner information is known.
Animal Owner's Name -

First NameLast Name
Phone Number -

Area CodePhone Number
Address -

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional notes or contact information -

Physician Information
Physician Name -

First NameLast Name
Name of Practice -
Address of Practice -

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number -

Area CodePhone Number
Additional notes or contact information -

Rabies PEP Information

If you have questions about PEP treatment, contact Larimer County Health Department at 970.498.6775
Has rabies PEP started?

YesNoUnknown
Has local Health Department recommended rabies PEP?

YesNoUnknown

Bite Information
Address where bite occurred -

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Circumstance of bite -
Behavior (e.g., was animal healthy, ill, or exhibiting abnormal behavior?) Explain:
Additional notes -

Submit a photo of injury
Add another photo
Add another photo
Please submit a picture of the to help confirm the injury.
Once Larimer Humane Society receives your report the information will be verified and the owner will be contacted. For rabies observation; state health laws require the bite animals be confined for a period of 10 days. Once the 10 days have passed the healthy animal will be relesed from confinement.
Should be Empty: