Rabies Prevention and Control – Animal Exposure Report
For Physician / Practitioner Use
REPORTING AN ANIMAL
EXPOSURE?
Reporting healthcare provider should complete
the form and fax to 416-696-4297
OR
To report by telephone:
Call 416-338-7600 (weekdays 8:30 to 4:30 pm)
Call 311 (evenings, weekends & stat holidays)
ORDERING POST-EXPOSURE
PROPHYLAXIS?
Do not use / complete this form.
Speak with TPH staff by telephone to discuss
the risk assessment and/or to order PEP:
Call 416-338-7600 (weekdays 8:30 to 4:30 pm)
Call 311 (evenings, weekends & stat holidays)
Healthcare
Provider
Information
(HCP)
Reporting Date (mm/dd/yyyy)
Ont. Govt. Pharmacy #
First Name Last Name (or Single Name) Telephone Number (incl. ext.)
Address (Num. & street)
Unit
City Province Postal Code
Patient
Information
*Patient ID
label/MRN can be
applied here
First Name Last Name (or Single Name)
DOB (mm/dd/yyyy)
Parent/Guardian Name (if victim under 16) Telephone Number
Home
☐Work ☐Cell ☐
Address (Num. & street)
Unit
City Province Postal Code
Risk
Assessment
Details
(completed by
HCP)
Nature of Exposure
Bite☐ Scratch☐ Other☐
If Other,
Specify:
Bleeding / Break to Skin
Yes☐ No☐
Wound Location
Arm☐ Hand☐ Head☐ Neck☐ Leg☐ Mucosa☐ Torso☐ Unknown☐ Other☐
If Other,
Specify:
Incident Date (mm/dd/yyyy) Incident Location (City, Province, Country)
Circumstances of Incident
Provoked ☐ Unprovoked ☐
Animal Species
Cat☐ Dog☐ Raccoon☐ Bat☐ Other☐
If Other.
Specify:
Animal
Information
(may be
completed by HCP
or patient)
Owner/Custodian First Name Owner/Custodian Last Name (or Single Name)
Telephone Number
Home
☐Work ☐Cell ☐
Owner/Custodian Address (Num. & street)
Unit
City Province Postal Code
Incident Description (include description of animal breed, colour, size, animal behaviour)
Personal information on this form is collected under the authority of the Health Protection and Promotion Act, R.S.O. 1990, c. H. 7. The information is used for enforcing the Act,
processing demand calls, and aggregate statistical reporting. The information is used to conduct a Rabies Control investigation and for aggregate statistical reporting. Questions about
this collection can be directed to Manager, Healthy Environments (Zoonotic Disease Program Lead) 5100 Yonge Street, Toronto, M2N 5V7. Telephone is 416-338-8410.
toronto.ca/health/professionals
