Fillable Vermont Department of Health Laboratory Request for Rabies (Vermont Department of Information and Innovation on behalf of Vermont Dept of Health)

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Vermont Department of Health Laboratory Request for Rabies (Vermont Department of Information and Innovation on behalf of Vermont Dept of Health)

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The Vermont Department of Health Laboratory Request for Rabies (Vermont Department of Information and Innovation on behalf of Vermont Dept of Health) form is 1 page long and contains:

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BROWSE VERMONT DEPARTMENT OF INFORMATION AND INNOVATION ON BEHALF OF VERMONT DEPT OF HEALTH (VT) FORMS

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Micro 201 Rev 9 August 2018 FILL OUT A SEPARATE FORM FOR EACH SPECIMEN Page 1 of 1
Vermont Department of Health Laboratory
Request for Rabies Examination
Mailing Address: PO Box 1125, Burlington, VT 05402-1125
Shipping and Drop Off Address: 359 South Park Drive, Colchester VT 05446 ● (802) 338-4724 or (800) 660-9997 in VT only
NOTE: All rabies testing requests must be pre-approved by Infectious Disease Epidemiology
Check here if request has been approved by calling: (802) 863-7240 or 1-800-640-4374 (available 24/7)
C
omments (additional comments may be written on the back of this document):
*
Human Exposure is only when wet saliva or nervous tissue from a suspect animal is directly introduced into open wounds and/or mucou
s
m
embranes (e.g. mouth, nose, eyes), or exposure to a bat where there is uncertainty of a bite.
Submitter Information (e.g. Game Warden, Veterinarian)
Facility or Agency Name:
Last Name:
First Name:
Mailing Address:
City/Town:
State:
Zip Code:
Telephone Number (Day):
Telephone Number (Evening):
Shipping Address (If Different from Mailing Address):
Large Rabies Box Animal Kit (Indicate number needed):
Small Rabies Box Animal Kit (Indicate number needed):
Complainant Information (e.g. Animal Owner)
First Name:
Address:
City/Town:
State:
Zip Code:
Telephone number (Evening):
Reason for Test:
Human Exposure * Contact With Pet or Domestic Animal Diagnostic Surveillance
Human Exposure Information
Date of Exposure:
Type of Exposure:
Bite Contact with Saliva/Nervous Tissue
Name of Person(s) Exposed:
Telephone Number of Exposed (Day):
Telephone Number of Exposed (Evening):
Animal Information
Animal Type:
Age of Bovine (If Applicable):
Animal/USDA ID Number:
Date of Death:
Town Captured/Found:
County Captured/Found:
State Captured/Found:
Latitude (USDA):
Longitude (USDA):
Porcupine Quills Present?
YES NO
More than One Specimen in Box?
YES NO
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Vermont Department of Health Laboratory Request for Rabies (Vermont Department of Information and Innovation on behalf of Vermont Dept of Health)

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Completed 13 August 2020

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