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DOH-61 Rabies (1/05) NEW YORK STATE DEPARMTENT OF HEALTH Bureau of Community Environmental Health and Food Protection Children’s Camp Program Potential Rabies Exposure Report See Environmental Health Manual Procedure CSFP-146 and back of form before completing. Camp Exposure Date: Time: (Military time) Report Date: eHIPS Log Number: Rabies Analysis- Provide the following information for each animal involved in the incident. Animal Description Submitted for Rabies Analysis If Submitted for Analysis, Indicate Results #1 J Yes J No J Positive J Negative J Untestable #2 J Yes J No J Positive J Negative J Untestable #3 J Yes J No J Positive J Negative J Untestable #4 J Yes J No J Positive J Negative J Untestable If exposure was a result of a bat entering a building, were bat exclusion techniques utilized after the incident to prevent future bat entry and potential human exposure? Yes No COMPLETE FOR ALL PERSON(S) INVOLVED IN THE EXPOSURE INCIDENT – Shaded information is confidential 1. Victim Information: eHIPS Victim Number: Exposure Date Time (military) Name of Patient: (Last, First, M.I.) Home Address: Parent or Guardian Home Phone Number ( ) Age: I__I__I Sex: Male Female Status: Camper Developmentally Disabled Camper CIT/Jr. Counselor Counselor Other Staff* Other* Animal Type of Exposure (select from back of form) Animal Type of Exposures (select from back of form) #1 #3 #2 #4 Was postexposure prophylaxis (PEP) recommended? J Yes J No Was PEP administered? Yes No Refused 2. Victim Information: eHIPS Victim Number: Exposure Date Time (military) Name of Patient: (Last, First, M.I.) Home Address: Parent or Guardian Home Phone Number ( ) Age: I__I__I Sex: Male Female Status: Camper Developmentally Disabled Camper CIT/Jr. Counselor Counselor Other Staff* Other* Animal Type of Exposure (select from back of form) Animal Type of Exposures (select from back of form) #1 #3 #2 #4 Was postexposure prophylaxis (PEP) recommended? J Yes J No Was PEP administered? Yes No Refused 3. Victim Information: eHIPS Victim Number: Exposure Date Time (military) Name of Patient: (Last, First, M.I.) Home Address: Parent or Guardian Home Phone Number ( ) Age: I__I__I Sex: Male Female Status: Camper Developmentally Disabled Camper CIT/Jr. Counselor Counselor Other Staff* Other* Animal Type of Exposure (select from back of form) Animal Type of Exposures (select from back of form) #1 #3 #2 #4 Was postexposure prophylaxis (PEP) recommended? J Yes J No Was PEP administered? Yes No Refused 4. Victim Information: eHIPS Victim Number: Exposure Date Time (military) Name of Patient: (Last, First, M.I.) Home Address: Parent or Guardian Home Phone Number ( ) Age: I__I__I Sex: Male Female Status: Camper Developmentally Disabled Camper CIT/Jr. Counselor Counselor Other Staff* Other* Animal Type of Exposure (select from back of form) Animal Type of Exposures (select from back of form) #1 #3 #2 #4 ---PAGE BREAK--- DOH-61 Rabies (1/05) Was postexposure prophylaxis (PEP) recommended? J Yes J No Was PEP administered? Yes No Refused ---PAGE BREAK--- DOH-61 Rabies (1/05) Instructions for Completing the Children’s Camp Rabies Exposure Report Form For each exposure incident, complete the requested information for all persons exposed. A separate form must be utilized for each incident. An incident can be exposures of one or more people to one or more animals over the course of a period of time (onsite petting zoo) or to a single animal one time. The local health department Rabies Coordinator must be consulted to arrange for and determine the appropriateness of postexposure prophylaxis (PEP). A copy of the Children’s Camp Potential Rabies Exposure Incident Report should be sent to the Rabies Coordinator for their records. When an exposure occurred over a period of time, indicated the first exposure date and time as that for the incident and specify each victims exposure date and time in the victim information section. When an exposure is a result of a bat inside a building, the path of entry must be identified and the appropriate exclusion techniques to prevent future exposure(s) must be employed. TYPE OF EXPOSURE - Using the coding scheme below, indicate the letter that corresponds to each victim’s type(s) of exposure; up to four letters may be selected, if appropriate. When multiple animals are involved with a single incident, consistency must be maintained between the animal number designation in the “Rabies Analysis” section and the animal number designation in the "Type of Exposure" section. The below exposure types have a reasonable probability of transmitting rabies and must be reported to the Local Health Department by the camp. In general, PEP is recommended for these exposures when rabies exposure cannot be ruled out. A-C can be used for all exposures, D-M are for bats only. Select N only after consultation with the Bureau of Community Sanitation and Food Protection and describe the exposure in the narrative. A = Bite. B = Scratch. C = Saliva or nervous tissue contact. D = Direct physical contact with live or dead bat. E = Person touched bat without seeing the part of bat touched. F = Bat flew into person and touched bare skin. G = Bat flew into person on part of body with lightweight clothing and the person reports feeling an unpleasant sensation at the point of contact. H = Person with bare feet stepped on bat. I = Person awakens to find a bat in the room with them. J = Live bat found in room with unattended infant, child, or person with sensory or mental impairment. K = Person slept in small, closed-in camp cabin, bats swooping past while sleeping. L = Bat found on ground near unattended infant, child, or person with mental impairment. M = Unidentified flying object hits person and time of day (dusk or dawn), presence of mark where hit, and place where flying object came from good site for roosting bats) all support likelihood that it was a bat. N = Other Narrative: Provide a description of the exposure incident. When the exposure was a result of a bat entering a building, state which building the exposure occurred in. Children’s Camp Local Health Telephone Date Rabies Coordinator Consulted: Date Form Sent to Rabies Coordinator: