Delaware Health and Social Services / Division of Public Health

Report of Potential Human Exposure to Rabies

Please Fax to DE Division of Public Health at (302) 739-3171 as Soon as Possible

VICTIM
 
Name: ____________________________          M       F     Age _____    ___________________________
                   First                           Last                                                                                              Parent’s name if under 18

Address: ______________________________________________________   _______________________
                              Street                                               City                                State          Zip              Daytime  Telephone  Number

Date of Incident: _______________     Wound Location: ________________________________________
                                          MM/DD/YY                                                                         (Hand,  Arm,  Leg,  Face,  etc.) 

Wound Severity:       Skin Not Broken             Scratch            Bite             Laceration              Puncture Wound

Treatment:            Basic Wound Care              Tetanus               Sutures               Antibiotics             Rabies Vaccine and HRIG

Location of Incident _____________________________________________________________________
                                                                                   Address,  Place,  or  Location  of  Incident

Details of Incident: ______________________________________________________________________
                                                                                              How  Did  Incident  Occur ?

ANIMAL

     Dog               Cat            Other __________________________________________________________
                                                                                      Please Indicate Species of Animal

Description: ___________________________________________________________________________
                                                   Color,   Markings,   Breed,   Hair Length,   Size,   Weight,   Sex,   etc.

Owner Known:         No          Yes      If Yes, please provide animal owner’s information below.

Name: __________________________________________ Daytime Phone: ________________________

Address: ______________________________________________________________________________
                                       Street                                                                                City                                              State            Zip

For Rabies Disease Prevention Information:
Please Call DPH Rabies Hotline at (302) 744-4545

For Rabies Animal Control Services - Anywhere in Delaware:
Please Notify Kent County SPCA at (302) 698-3006

Name of Person Taking Information: ___________________________________ Date: _______________
                                                                                           First                          Last                                                     MM/DD/YY

Name of Hospital or Facility: _________________________________________ Phone: ______________