Utah Online Reportable Disease Form

UDAF Reportable Disease Form

Animal Industry Division / Animal Health Program
Veterinarian Information
Vet Name *

First Name Last Name
Clinic Name
Veterinarian/Clinic Phone Number *

Area Code Phone Number
Veterinarian/Clinic Email *
example@example.com
Owner Information
Owner Name *

First Name Last Name
Owner Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Owner Phone Number *

Area Code Phone Number
County *
Animal Information
Species *
Species (OTHER)
Animal Name/ID *
Age *
Breed *
Sex *
Number of other animals on the premises:
Disease Information
Disease *
Other (specify)
Tests
Diagnosis (confirmed or suspected)
Date of Onset

Month Day Year
Date
Has the horse traveled in the previous 30 days?

Yes No
In-State Travel?

Yes No
Date and location of in-state travel
Out of State Travel?

Yes No
Date and location of out-of-state travel
What is the horse used for?
Vaccination Status:

WNV WEE EEE VEE Rabies
Animal Status

Dead Alive Euthanized Recovering
Animals the horse has had contact with:

Horses Cattle Sheep or goats Swine Poultry Wildlife
If a mare, is she pregnant?

Yes No Unknown
Where is the horse housed? (check all that apply)

Stable Pasture Dry paddock
Clinical Signs (check all that apply)

Weakness Ataxia Abnormal mentation Fever Fasciculation Anorexia Cranial nerve deficits Flaccid paralysis Teeth grinding Unable to rise
Specimen type submitted to lab

Serum (acute) red top Serum (convalescent) red top Nasal swab Whole blood CSF Brain/CNS tissue
Native to Utah?

Yes No
If no, where is the animal from?
Has the animal traveled out of state?

Yes No Unknown
If yes, where?
Is the animal symptomatic?

Yes No
If yes, date of onset of symptoms
Is the animal on heartworm preventative?

Yes No
Antigen test results

Positive Negative
Microfilaria test results

Positive Negative
Disease

American Foulbrood European Foulbrood Varroosis of honey bees Acarapisosis of honey bees Small Hive Beetle infestation Tropilaelaps infestation
Total number of hives
Number of affected hives
Location of hive (lat)
Location of hive (long)
Other test results
Disposition of case

Treated Euthanized Undecided
Type of rabbit

Domestic Feral Wild
Number of Dead Rabbits
Contact with wild rabbits?

Yes No
Hemorrhage from nose?

Yes No
Confirmed by Lab?

Yes No
If yes, lab accession #?
Other information
Should be Empty:

UDAF Reportable Disease Form

Veterinarian Information

Owner Information

Animal Information

Disease Information