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Rabies post exposure prophylaxis (rPEP) administration report, form B

When contemplating 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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Was KFL&A Public Health consulted?

Yes

If yes, name of the person consulted

The following information is required if (rPEP) is administered.

Patient last name

Patient first name

Patient date of birth

Patient phone number

Patient address

Was rabies immune globulin (Rablg) given?

Yes

Do not administer rabies vaccine in the same site as Rablg, or using the same syringe.

Type of rabies vaccine given

Human Diploid Cell Vaccine: Imovax

Purified Chick Embryo Cell Culture: Rabavert

Imovax and Rabavert are interchangeable.

Administration schedule

Day 0, date (if not completed on Form A)

Lot number

Day 3, date

Lot number

Day 7, date

Lot number

Day 14, date

Lot number

Previously unimmunized immunocompromised persons (including those taking corticosteroids or other immunosuppressive agents, and those who have immunosuppressive illnesses), and those taking chloroquine and other antimalarials, should continue to receive a five dose vaccination regime on days 0,3,7,14, and 28, with one dose of Rablg on day 0.

Day 28, date

Lot number

Please complete and submit a Form A (Animal Bite or Suspected Rabies Exposure Reporting) along with this form when rPEP has been initiated AND when the patient completes or stops the vaccine series.

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

Yes

E-mail address

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.

Form Builder

Rabies post exposure prophylaxis (rPEP) administration report, form B

Print to PDF

The following information is required if (rPEP) is administered.

Do not administer rabies vaccine in the same site as Rablg, or using the same syringe.

Administration schedule

Please complete and submit a Form A (Animal Bite or Suspected Rabies Exposure Reporting) along with this form when rPEP has been initiated AND when the patient completes or stops the vaccine series.

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