Animal Bite / Rabies Exposure Report Form

In New York State, health care providers are required to report any potential human rabies exposures to the local Health Department.  This includes all animals bites and scratches from both wild and domestic animals, regardless of rabies vaccination status.  Once the report is filed, we will investigate the circumstances of the incident to determine whether or not post-exposure rabies treatment will be necessary.

This webform is intended for use by health care providers when submitting reports of a potential exposure.  Alternatively, a fillable pdf can be downloaded at the bottom of this page and email to () or printed and faxed to (716) 701-3737.

Blocks marked with an asterisk (*) are required.

Name of the person or organization reporting the animal bite / rabies exposure

Date when the animal bite / rabies exposure occurred

Name of the person bitten / exposed

Age of the person bitten / exposed

If the person bitten or exposed is a minor, enter the name of the parent or guardian to be contacted

Address of the person bitten / exposed

Town or City, State and Zip code where the person bitten / exposed resides

Telephone number of the person bitten / exposed (or parent / guardian)

Email address of the person bitten / exposed

Where on the body was the person bitten / exposed

Describe any medical treatment administered to the person exposed / bitten

Name of the family physician that may be contacted regarding the animal bite / exposure

Telephone number the family physician may be contacted at

Species of the animal that bit / exposed the person above

Breed of the animal

Describe any identifying features of the animal that bit / exposed the person above

Is the animal owned or a wild animal / stray?

Name of the animal's owner

Street Address of the animal's owner (if domestic)

Town or City, State, and zip code where the animal's owner resides

Telephone number of the animal's owner

Did the animal have a current rabies vaccination at the time of the bite / exposure?

Place of most recent rabies vaccination

Date of most recent rabies vaccination

Describe the circumstances of the bite / exposure, or any other information that may be helpful during investigation of the incident

AttachmentSize
CCHD - Rabies Exposure Report Form 7-14.pdf510.19 KB
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