Animal Bite / Rabies Exposure Report Form | Cattaraugus County Website

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. There is a fillable pdf at the bottom of this page, that can be filled out and faxed to (716) 701- 3737.

Blocks marked with an asterisk (*) are required.

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Reported by

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

Date of the Bite / Exposure

Date when the animal bite / rabies exposure occurred

Person Exposed

Name of the person bitten / exposed

Age

Age of the person bitten / exposed

Parent / Guardian

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.

Address of Person Bitten

City/Town of Person Bitten

State/Province of Person Bitten

ZIP/Postal Code of Person Bitten

Telephone

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

Optional

Please confirm email address

Re-enter email address for confirmation.

Location of the Wound

Where on the body was the person bitten / exposed

Description of Medical Treatment Administered

Describe any medical treatment administered to the person exposed / bitten

Physician

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

Physician's Telephone

Telephone number the family physician may be contacted at

Animal Species

Species of the animal that bit / exposed the person above

Animal Breed (if applicable)

Breed of the animal

Description of the Animal

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

Ownership Status

Is the animal owned or a wild animal / stray?

Domestic (owned)

Wild/Stray

Owner of the Animal (if applicable)

Name of the animal's owner

Address of the animal's owner (if domestic)

Address of animal's owner

City/Town of animal's owner

State/Province of animal's owner

ZIP/Postal Code of animal's owner

Owner's Telephone (if applicable)

Telephone number of the animal's owner

Rabies Vaccination Status

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

Yes

Unknown or N/A

Place of Vaccination (if applicable)

Place of most recent rabies vaccination

Date of Vaccination (if applicable)

Date of most recent rabies vaccination

Circumstances of Bite / Exposure or Other Comments

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

Health Department

Contact Information