Animal bite or suspected rabies exposure reporting form A

When contemplating Rabies Post Exposure Prophylaxis (rPEP), please follow the Management of patients with suspected rabies exposure - guidance for health care providers working with your local health unit.

If circumstances fall outside these guidelines, or if you have any questions, please contact KFL&A Public Health's Environmental Health Team at 613-549-1232.

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Weekends and holidays:

Please call the after hours line at 613-549-1232. Staff will not be available to respond to this electronic form during those times.

Form completed by

Other:

Contact E-mail address (to receive receipt of submission)

A. Person exposed

Victim's Last name

Victim's First name

Is the victim under 18 years of age?

Yes

No

Victim's date of birth

If yes, name of parent or guardian

Victim's address

City

Victim's phone number

B. Animal owner

Is the owner information the same as the victim's information above?

Yes

No

Animal owner is unknown

City (animal owner)

C. Incident information

Date incident occurred

Type of exposure

Skin break

Saliva on open wound

Bat to skin contact

Other

Other:

Location of wound

Details of incident

Animal species

Dog

Cat

Bat

Other

Other:

Animal name, if known

Type of animal

Domestic pet

Farm animal

Stray animal

Wild animal

Animal breed (if known)

By checking this box, I acknowledge I have read, understand, and agree that the information provided in this form is correct.

Yes

Personal information on this form is collected under the authority of the Health Protection and Promotion Act R.S.O. 1990, c.H.7,s.26; R.R.O. 1990, Reg. 569, s.1(2), amended and in accordance with PHIPA and will be used for assessment, management, treatment, and reporting purposes. Questions about this collection should be addressed to the Medical Officer of Health at KFL&A Public Health, 221 Portsmouth Avenue, Kingston, ON K7M 1V5. 613-549-1232, or 1-800-267-7875.

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Animal bite or suspected rabies exposure reporting form A

Weekends and holidays:

A. Person exposed

B. Animal owner

C. Incident information

For a printed copy of this form for patient records, please print page before pressing submit.