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RAB-01 Rev 09/22/2017 J:\Environmental\Environm\WPDATA\rabies\FORMAT - Rabies Letters\RAB-01_rabies_suspect_incident_report.doc CORTLAND COUNTY HEALTH DEPARTMENT HEALTH DEPARTMENT LOG # 60 CENTRAL AVENUE Room 120 PHONE # [PHONE REDACTED] CORTLAND, NEW YORK 13045-2746 FAX # [PHONE REDACTED] RABIES SUSPECT INCIDENT REPORT Contact with human Yes/No Contact with pet Yes/No Date incident occurred Time of am/pm victim* Road Address where incident occurred: other Town of County of BACKGROUND OF ANIMAL(S) AND Owner(S) Type of wild Y/N Type of domestic M/F & Markings_____________________Animal Vaccinated for Rabies Y N Unknown Date of Vaccination______________1 yr 3 yr Veterinarian and phone Mailing Confidential information: (not to be released) BACKGROUND OF VICTIM of Weight Parent(s) or Legal Guardian(s) (if Probable Rabies Prophylaxis Authorized? Yes / No Date______________Authorized Rabies PET started? Yes / No Date:see MD records Previous Rabies PET? Yes / No Date: If bat exposure, were other people in the room? Yes / No If yes, complete an incident report for each. Please complete the following if Rabies Treatment is given: Name of Private Insurance OFFICE USE ONLY Reported to Health Dept by victim* other Agency Date reported to Health Dept Report received at CCHD by Dates of Confinement/Quarantine from to Confined at 10 day verification by Date Alive & Well? Yes/No Vaccination verified Yes/No By who Booster verified Yes/No By Referred out of county to Date specimen sent to LAB Results Date of DOH Contacted Owner Yes/No Date Contacted Victim Yes/No Date Referred to Nursing: *If victim is same address as owner, information is also confidential and may not be released. ---PAGE BREAK--- RAB-01 Rev 09/22/2017 J:\Environmental\Environm\WPDATA\rabies\FORMAT - Rabies Letters\RAB-01_rabies_suspect_incident_report.doc DATE COMMUNICATIONS - NARRATIVE INITIALS