HomeMy WebLinkAboutMiscellaneous - 65 Marblehead �,
�_
�� `
I
f
I
I
� �i
I I
� f
i
I �
'�
REQUEST FOR RABIES EXAMINATION APPENDIX #9
Center liar Labointofifilt I'lid C0111MI11 IDAt)IA M6011ee Control n _
,. Lob No..
Rabies Laboratory (61 T) 52273700, Ext. .tyh
Person or Agency Owner or Person
�� / A?l 'Submitting Specimen �/�� ��-�� /1�M Who Found Animal �r'(.I�Y(�� 1r .�r��0/7 •
Street r��� S' [ l�-�i'LL Street)/ Y 't-
City City r�o (��i�(ll.tl fr (Y) - )
State, Zip �/R/O _Phone !q)( "•_c�OGO Stale, Zip_ urs,,-IS Phone_ 0/
ANIMAL � 'y -�
SUBMITTED ANIMAL: Species �% �i Breed /1 ��f{�.IPAgj_._L_, ( Petvj
Stray Wlld❑ Unknown❑
Neurologic or behavioral signs observed during period 1 week before thru 16 days after biting incident:
Describe:
Cause o Death:eath: Natural❑ Killedw Method-e.,,Jhc,Yr�Date and Time of Death iL l I I G c� �
"%,�cinated for Rabies: Unknown NOD Yes[] Type of Vscclne Det®
Travel Out of State: Unknown No❑ Yes[] ((,Wirere When
Bitten by another animal within 12 months: Unknown ll' NOD Yes❑ Species of Biter- Date:
Where was animal found or collected, i.e., city/town
l rt-lr! ;c.Vv'L _CountySS,=?�'
ANIMAL(S) BITTEN BY SUBMITTED ANIMAL:
Animal's Name: Species: Date of Bite: Vaccinated for Rabies*—
Name of Owner: —
Address_ _ Tel.No.
PERSON(s) BITTEN
PERSON(S) BITTEN BY SUBMITTED ANIMAL: If more than one person has been bitten, please
Include the some Information for each additional
Name i�� ( Z) %l( ��i�/�� person on the reverse side.
NO❑ Ye
Street Was bite provoked? Unknown ti❑
/,
city/State/zip �6 ������ iP� �� `L j Site of Bite: )
Phone:_
Date of Bite � Severity of Bite:
Was Victim Treated? Unknow No❑ Yes Town where bite occurred_ ��� o
If YES, give name, address & Tel. No. of attending physician, clinic and vaccinations received:
-- r
NOTE: Local Health Dept. should be notified of all animal bites.
( �tlon on specimen and/or biting episode
Use reverse side for additional Inform )
LABORATORY RESULTS - FLUORESCENT RABBES ANTIBODY (FRA):
c �;
0UNSATISFACTORY
N 1 x,u 'i k,
N
"i' NEGATIVE (Not Rabid)
�?��
m tics.,` POSITIVE (RABID)
0
(;nttttttanla; .
LL -4R -