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 -

- Month - Day Year
Date

Patient Information
Patient Name -

First Name Last Name
Phone Number -

- Area Code Phone Number

Address -

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Additional notes or contact information -

Owner Information

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

First Name Last Name
Phone Number -

- Area Code Phone Number

Address -

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Additional notes or contact information -

Physician Information
Physician Name -

First Name Last Name
Name of Practice -

Address of Practice -

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number -

- Area Code Phone 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?

Yes No Unknown
Has local Health Department recommended rabies PEP?

Yes No Unknown

Bite Information

Address where bite occurred -

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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.
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