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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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
Heartworm
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
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
Submit
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