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
*
Apis (bees)
Bovine (Cattle, Bison, Buffalo)
Equine (Horse, Mule, Donkey)
Ovine (Sheep)
Caprine (Goats)
Canine
Feline
Avian
Poultry
Rabbit
Other
Species (OTHER)
Animal Name/ID
*
Age
*
Breed
*
Sex
*
Male intact
Male neutered
Female intact
Female spayed
N/A
Number of other animals on the premises:
Disease Information
Disease
*
Apiary Diseases
Equine Neurologic Disease
Rabbit Hemorrhagic Disease
Other (specify)
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
Other
If a mare, is she pregnant?
Yes
No
Unknown
Where is the horse housed? (check all that apply)
Stable
Pasture
Dry paddock
Other
Clinical Signs (check all that apply)
Weakness
Ataxia
Abnormal mentation
Fever
Fasciculation
Anorexia
Cranial nerve deficits
Flaccid paralysis
Teeth grinding
Unable to rise
Other
Specimen type submitted to lab
Serum (acute) red top
Serum (convalescent) red top
Nasal swab
Whole blood
CSF
Brain/CNS tissue
Other
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
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