Animal Bite Reporting Form   Delaware Health and Social Services / Division of
Public Health
 
                   
Report of Animal Potentially Exposed to Rabies
 
Fax to DPH Rabies Program at 302-739-3171
 
 
Owner’s Name:
________________________________________________________________________
 
Physical Address (No P.O. Boxes or R.D. Numbers):
______________________________________________________________________________________
 
Mailing Address (If different from above):
_________________________________________________
 
Daytime Phone Number:
________________________________________________________________
 
Animal’s Name: ______________________________  Age: ____________            
Male            Female
 
Description:      CAT                DOG                  
OTHER__________________________________________
 
Breed: ___________________
Markings____________________________________________________
 
Rabies Vaccination Status:        Current Until __/__/__             Expired:
__/__/__             UNKNOWN
 
Date of Injury: __/__/__    Location and Type of Injury:
______________________________________
 
Circumstances of Injury:
________________________________________________________________
 
Submitting Office:  (Name, Address, Phone number)
_______________________________________________________________________________­_______
 
Veterinarian
Signature__________________________________________________________________
 
For Currently Vaccinated Animals:
 
Animal was given rabies booster on __/__/__, and owner has been informed of
45-day quarantine requirement.  Instructions have been given to owner for
compliance with 45-day quarantine.
 
Owner’s signature: _____________________________________________________   Date:
__/__/__
 
######################################################################################
 
For Animals Not Currently Vaccinated For Rabies:
 
Owner has been informed of the ONLY TWO OPTIONS available: Euthanasia or 6-month
isolation quarantine.  If owner chooses quarantine, it is effective IMMEDIATELY,
and instructions have been given for compliance until details are received from
Division of Public Health Rabies Program.
 
Owner’s Signature: _____________________________________________________   Date:
  __/__/__