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HomeMy WebLinkAboutRabies - 1999REQUEST FOR RABIES EMkNE 1YATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385,-6387 i' SIJB1tITTER /c::U,� �i/�i.✓r.�: FOR LA&USE;ONLY g Date: Received: %-L —/*/ Lab.No:: AG' — 453 Agency Owner or Person Who Found Animal Street fu Ltri-rfi s'7: Street City/State/Zip iJfeitAle%4. Aj. il270 Z F CitylStatetzip Phone ( ZF) del - 7.tea Phone ( ) SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: s Breed DSf/ Age ❑ Pet Jai Stray ❑ Wild ❑ Unknown Why is animal to be tested? X'Human exposure ❑ Pet exposure ❑ Acting sick Symptoms: XAggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures Ci�Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural AKilled Method �7- 71.� Date of death i A7AP Vaccinated for rabies: ❑ Yes ❑ No p Unknown Date of vaccination . Travel out of state: ❑ Yes ❑ No R'Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No q Unknown If yes, by what? In what TOWN was animal L= ? In what ? Ay. r'Td/ EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street t/r vTis s% CilylStatelZp. 1-414 i ze tiY Phone (5-c g) Type of exposure: Bite . ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure 11;7f- %9 Body site ENT Severity of exposure �/1 r' fce` Circumstance of exposure: Cl Capture j&Handling ❑ Specimen prep. ,9Unprovoked attack ❑ Provoked attack ❑ Indirect exposure Cl Other Was person previously vaccinated? ❑ Yes j4 No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes $) No ❑ Unknown PhysicianlHospital Phone ANIMAL(S) EXPOSED: Name Species Owner t6et City/State/Zip Phone ( ) Type of exposure: ❑ Site ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure Circumstances of exposure: ❑ Fight ❑ Vicinity ❑ Other ❑ Dead animal contact Was animal's rabies vaccination up-to-date? ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes ❑ No ❑ Unknown LABORATORY RESULTS' FLUORESCENT RABIES.ANTIBOOY'TES.T Test Date POSITNE:(RABID) ❑ NEGATIVEr(NOT RABID) SPECIMEN UNSATISFACTORY ❑ COMMENTS: � Crl& Massachusetts Department of Food and Agricufture A�.C�`# Division of Regulatory Services , Bureau of Animal Health NOTICE OF POSSIBLE EXPOSURE TO RABIES AND QUARANTINE ORDER Your pet may have been exposed to rabies as a result of recent exposure to wildlife or a high -risk domestic animal. If your animal is unvaccinated, you are strongly urged to have it euthanized (unless animal was only exposed by proximity). If you do not, you are hereby ordered to (check appropriate measure): isolate your pet for 3 months, followed by 3 months of strict confinement. Vaccinate the animal 1 month prior to release, and revaccinate between 9 and 12 months later. strictly confine your pet for 6 months, and vaccinate the animal 1 month prior to release, and revaccinate between 9 and 12 months later. vaccinate your pet immediately and closely observe the animal for 6 months, revaccinate between 9 and 12 months later. If your animal is currently vaccinated, you are hereby ordered to: vaccinate your pet immediately followed by 3 months strict confinement. vaccinate your pet immediately and closely observe the animal for 3 months. You are to inform your veterinarian immediately of any unusual behavior or change in the health status of this animal. Any animal which dies for any reason while und quarantine must be submitted for rabies testing. 6,0e-Y��il'�— v,imnl� Animal was euthanized. (C�� p DATE OF EXPOSURE:\)\\60L0)1(-Yeje,,,6 1 I e' I k m /. \ U'/ 3 V Name of Owner: \ of e �/ NNo�o,,.: IJ . 7-SSl1 Address: �1LN",--e..4 �J nnP,,{{hone Town: /-�Ahn')e-1ozip: 0c40x/8 _ Type of Animal: VDog Cat Other (specify) Name of Animal: 6kol'W�YGC-\,L- Breed: 4�a, �e_,-Y�eVPYColors: 1,"O'0.C.1� I ? Age:n�ir Date of last rabies vaccination prior to exposure: Vacc n7tion Ow1�-Y 51 yS Vp lG Duration: 1 yr_3 yr_ Unknown Date of post exposure Saccination (to be given to current vaccinates only) Date of Order of Quarantine Name of Veterinarian: �-)0V0VC-y-\JeAr\ Phone No.: Name of Animal Inspector; ( �(' Le j Ie Town; MaY\�§��� Phone No.: Signature of Animal Inspector Date: See back side of this form for explanation of Isolation, Strict Confinement, Close Observation, Exposure by Proximity, Quarantine and Signs of Rabies. I hereby certify that I have read both sides of this document and I agree r.o foiiow the provisions described in it. Signature of Owner or Other Responsible Person Refused to sign, but Order was Issued Animal Inspector please initial if not signed OWNER'S COPY-- , This order is enforceable under 110L Chapter 129; section 21, 330 CMR 4.03. Massachusetts Department of Food and Agriculture Division of Regulatory Services Bureau of Animal Health NOTICE OF POSSIBLE EXPOSURE TO RABIES AND QUARANTINE ORDER Your pet may have been exposed to rabies as a result of recent exposure to wildlife or a high -risk domestic animal. If your animal is unvaccinated, you are strongly urged to have it euthanized (unless animal was only exposed by proximity). If you do not, you are hereby ordered to (check appropriate measure): isolate your pet for 3 months, followed by 3 months of strict confinement. vaccinate the animal 1 month prior to release, and revaccinate between 9 a:,d 12 months later. strictly confine your pet for 6 months, and vaccinate the animal 1 month prior to release, and revaccinate between 9 and 12 months later. vaccinate your pet immediately and closely obsarve the animal for 6 months, revaccinate between 9 and 12 months later. If your animal is currently vaccinated, you are hereby ordered to: vaccinate your pet immediately followed by 3 months strict confinement. vaccinate your pet immediately and closely observe the animal for 3 months. You are to inform your veterinarian immediately of any unusual behavior or change ill the health status of this animal. Any animal which dies for any rea bn while u der quarantine must be submitted for rabies testing.En v� cs.{- A�.,e_ -770 Animal was euthanized. DATE OF EXPOSURE:V yC C f JJJ Name of Owner: �._7� C' VW. Y--\C; ti0.y'PhoneNo. P(Yie� �Town: (1( E�� ZC�iAddress: p Type of An _Dog Cat_ Other (specify) Name of Animal: Breed: +-- l^ -7 Colors:l, Age:/6/e Date of last rabies vaccination prior to exposure: �� t Vaccination Duration: 1 r_3 r_ Unknown u-�' Date of nation�ito. e 5u':, Y Y post expdeure vaccination (to be given to current vaccinates only) Date of Order of Quarantine Name of Veterinarian: Or, HeCA'v ) Phone No. 6-1 Name of Animal Inspec, or: �.. t'_, .`.-� L-ol _ Town: Jy�,`t At P. Phone No.: ature of Animal Inspector Date: See back side of this form for explanation of Isolation, Strict confinement, Close Observation, Exposure by Proximity, Quarantine and Signs of Rabies. I hereby certify that I have read botri sides of this document and I agree :o :oi_j%q the provisions described in it. Signature of owner or Other Responsible Person Refused to sign, but Order was Issued Animal Inspector please initial if not signed OWNER'S COPY-- , This order is enforceable under MGL Chapter 129; section 21, 330 CMR 4.03. REQUEST FOR R-BIES E.YANMNATIOY State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 SUBtNtTTTER 17S-Col/;rS- FOR LAS:USE::ONLY Date. Received: 3 _ /Z//3 Lab No::. ,Ql�Lc39 Agency o�,, j,rc tiro c„ri P - /f r oiYrc Owner or Person Who Found Animal Street_ �n 6✓Cr-57_ rz- Street /3�0 F�F3� rr Cily/SlateOlp i�/� r /.�/Pc �/a n a ay CitylState/Zip _ PoaT/A�� �fF o y/ 0 3 ?hone (fib j 2f / _ 73 oo Phone (Zo9) L18 6 9 Y6 SPECTYIEN L`fFORNfATION (use reverse side for additional information) ANIMAL SPECIES: cs i vC Breed Age �� Nr ❑ Pet tray ❑ Wild ❑ Unknown Why is animal to be tested?�uman exposure ❑ Pet exposure ❑ Acting sick Symptoms: gression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural el'Killed Method �zbc ✓ Date of death 3 zz/y' 9 Vaccinated for rabies: ❑ Yes ❑ No �nknown Date of vaccination . Travel out of state: ❑ Yes ❑ No known Where When Bitten by another animal within 12 months: ❑ Yes ❑ No nknown If yes, by wh t? n what rM was animal found? / /� f t/�Q In what COUNTY? W/;T7 / INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name %i..> Street /?S d City/State/Zip Phone (.7v?) 87e— G 9' f Type of exposure: Cl Bite �cratch ❑ Lick ❑ Unknown ❑ Other Date of exposure Body site �,GflTf .gym Gc Seventy of exposure dl?Q kr,u sk,; ) Circumstance of exposure: ❑ Capture ❑ Handling Cl Specimen prep. Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes 4 No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes q No ❑ Unknown Physician/Hospital Phone AMMAL(S) EXPOSED: Name Species _ Owner _ Street City/State/Zip Phone ( ) Type of exposure: ❑ Bite ❑ Scratch ❑ Other Date of exposure Circumstances of exposure: ❑ Fight ❑ Vicinity ❑ Other ❑ Lick ❑ Unknown ❑ Dead animal contact Was animal's rabies vaccination up-to-date? ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes ❑ No ❑ Unknown LABORATORY RESULTS'- FLUORESCENT RABIE.5:ANT180DY'TEST Test Date POSITIVE, (RABID) ❑ NEGATIVE (NOT RABID) PECIMEN UNSATISFACTORY ❑ COMMENTS: 20 REQUEST FOR RABIES EM-kiY NATION Stare Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 FOR LA&USE ONLY Date: Received: 6 16 -5,57 Lab No... , / g SUBMITTERdyl Agency Owner or Person Who Found Animal Street S`a G /a s % s T Street Cly/StateOP _�jg �i�/ram f-/a o2 b 4S City/State/Zlp /Li r� ilc� rye onoy P Phone (55P) 26 /-733 i Phone 0?) 4 3 S - 5 83d SPECEMEY INFORMATION (use reverse side for additional information) ANIMAL SPECIES: /�� 8reed Age ❑ Pet ❑ Stray Wild ❑ Unknown Why is animal to be tested?19'Auman exposure 0 Pet exposure ❑ Acting sick Symptoms: ❑ Aggression O.Alaxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑Other Cause of death: ❑ NaturlKilled Method , ��7 Date of death 6 s 9 Vaccinated for rabies: ❑Yes ❑ No known Date of vaceination . Travel out of state: ❑ Yes . ❑ No �nknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No nknown If yes, by what? In what TOWN was animal found? G� /�:,��/O In what COUNTY.v ��— E:'CPOSt _RE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name �/��v9ica�cf Street 23 r - City/Slate1Zip _,,ti /1 :.r1W, oloye Phone (jjg) TYS-5P2,;' Type of exposure: ❑ Bite ❑ Scratch CI Lick Unknown ❑ Other Date of exposure Body site v 6�ra /(canes- S -�- Severity of exposure ' Circumstance of exposure: ❑ Capture ❑ Handling ❑ Specimen prep. Cl Unprovoked attack 0 Provoked attack Kndirect exposure /2f Other S�d/n Was person previou ly vaccinated? ° J ❑ Yes �o ❑ Unknown Did person recerve rag' ies shots after incident? ❑ Yes 94o 0 Unknown Physician/Hosp ifal P hone ANIMAL(S) EXPOSED: Name Species Owner gtreet City/State/Zip .Phone ( ) Type of exposure: ❑ Site ❑ Scratch ❑ Other_ Date of exposure Lick ❑ Unknown Circumstances of exposure: ❑ Fight 0 Vicinity ❑ Dead animal contact ❑ Other Was animal's rabies vaccination up-to-date? Cl Yes Cl No ❑ Unknown Did animal receive rabies booster after incident? 0 Yes 0 No ❑ Unknown LABORATORY RESULTS- FLUORE.SCENTRASIESANTI80D.Y'TES.T TestOate —i - POSIT/E:(RASID)❑ NEGATIVE: (NOT RABID) dN SPECIMEN. UNSATISFACTORY COMMENTS: i �� g J� 64 LOVV ,-P u s e SUBMITTER Agency ( eAm ✓ _ Owner or Person Who Found Animal PP2ug die Street �q� 'IAl nr �Pr rnV I:zr Street tU�<li Clty/Slstamp CRY/Stateop Phone (S7N ),So- Phone ( Szg) 3572 -- SPECIMEN INFORMATI N (use reverse sloe for additional Information) ANIMAL SPECIES: Breed � ff Age pet ❑ Stray ❑ Wild ❑ Unknown —L Why Is animal to be tested? � Human exposure ❑ Pet exposure ❑ Act ng s' Symptoms: ❑ Aggression jAtaAa Disorientation Lethargy ❑ ParayspisI Salivatkm 0Seizures ❑ Unexplained and ❑ ound dead ❑ O er Cause of death: ❑ Natural '�j Kllled Method -L-��� k v bateofdeath. a f zzf 719 r — Vaccinated for rabies: ❑ Yes ;, No ❑ Unknown Date of vaccination Travel out of state: ❑ Yes P No ❑ Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No Unknown If yes, by what? In what TOWN was animal [W17 �,1� M(� In what COUNTY? S : oL. ._ EXPOSURE INFORMATION (use reverse side for additional information) PERSONS) EXPOSED: Name �_�r 0 11 Q VLF Street -9—� r 5 - , Cily/StateOpo, ()Y 8 Phone(�p$) Type of exposure: ❑ Bite ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Cu--6L- Date of exposure Body site Severity of exposureM I y _ Circumstance of exposure: ❑ Capture THandling ❑ Specimen prep. ❑ Unprovoked alla8k ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes "�,No ❑ Unknown Did person receive rabies shots after Incident? ❑ Yes `I,No ❑ Unknown Physician/Hospital _ Phone LABORATORY RESULTS = FLUORFgrFnrraAair POSITIVE (RABID).❑ NEGA COMMENTS: CH 4 EXPOSE, D�I ) Name 'u �_� �� Street . S CilylStateMp IXU'nt- E oza7% Phone (S`0$) Type of exposure: ❑Bite ❑ Scratch--- E]-Udk Unknown ❑ Other w Date of expo�a - — Circumstances of exposure: ❑ Fight ❑ Vicinity ❑ Dead animal contact ❑ Other Was animal's rabies vaccination up-to-date? ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes ❑ No ❑ Unknown E (NOT RABIp)� DY TEST 7 estiDate SPECIMEN UNSATISFACTORY ❑ ct V: W1'tl aL. f c5/l�`el/e rl� 0 N L Y APPENDIX # Massachusetts Department of Food and Agriculture Division of Regulatory Services Bureau of Animal Health and Dairying y`. NOTICE OF POSSIBLE EXPOSURE TO RABIES AND ORDER Your pet may have been exposed to rabies as a result of recent exposure to wildlife < a high -risk domestic animal. If your animal is unvaccinated, you are strongly urged to hal it euthanized (unless animal was only exposed by proximity). If you do not, you are here) ordered to (check appropriate measure): isolate your pet for 3 months, followed by 3 months of strict conflnement,and vaccinal the animal 1 month prior to release. strictly confine your pet for '6 months, and vaccinate the animal 1 month prior I x release. vaccinate your pet immediately 'and closely observe the animal for 6 monu: revaccinate at 12 months. If your animal is currently vaccinated, you are hereby ordered to: vaccinate your pet immediately followed by 3 months strict confinement. vaccinate your pet immediately and closely observe the animal for 3 months. You are to inform your veterinarian immediately of any unusual behavior or change in the health status of this animal. Animal was euthanizedd.. Name of --owner:"+, ''/O11O C1X- Vm 0� Phone No.: q -Ill S 4ddr sarrnDS�7 0.fK , Town:�R[lfi i P /d Zip: Typ .of Anim 1:_Dog L< cat_ other (specify) L Name; pf` An al: Tg:s mine Breed: //cS / r colors:OM 1 If UT:, •' fi 9 �C ,r f 3 Ki' y r nr ' f�€ ��� dyl/Zz�ss Massachusetts Department of Food and Agriculture Division of Regulatory Services Bureau of Animal Health NOTICE OF POSSIBLE EXPOSURE TO RABIES AND QUARANTINE ORDER Your pet may have been exposed to rabies as a result of recent exposure to wildlife or a high -risk domestic animal. If your animal is unvaccinated, you are strongly urged to have it euthanized (unless animal was only exposed by proximity). If you do not, you are hereby ordered to (check appropriate measure): isolate your pet for 3 months, followed by 3 months of strict confinement. Vaccinate the animal 1 month prior to release, and revaccinate between 9 a:,d 12 months later. strictly confine your pet for 6 months, and vaccinate the animal 1 month prior to release, and revaccinate between 9 and 12 months later. vaccinate your pet immediately and closely obsarve the animal for 6 months, revaccinate between 9 and 12 months later. If your animal is currently vaccinated, you are hereby ordered to: vaccinate your pet immediately followed by 3 months strict confinement. vaccinate your pet immediately and closely observe the animal for 3 months. You are to inform your veterinarian immediately of any unusual behavior or change ill the health status of this animal. Any animal which dies for any reason %%%%while u deli, a quarantine must be submitted for rabies testing, \, (F� n C� Animal was euthanized. DATE OF EXPOSURE: L)n 1`�ht-jWy\ h )mC^`li wa- Name of Owner: ® � , 1 - Phone No.: A I Address: C-'0,5�- 20)OV R� Town:M ..a h5iie CQ Zip: C���/� _ Type of Animal: _Dog a -Cat_ Other (specify) Name �of Animal: 1-ClY� Le �{�_ Breed: il�. o Colors: Ce"- Age: (V'r Date of last rabies vaccination prior to exposure: ? Vagcinattion —� / bWhey"S� s vp aO a&t-e- Duration: 1 yr_3 yr_ Unknown v Date of post exposure vaccination (to be given to current vaccinates only) Date of order of Quarantine Name of Veterinarian: �/.y&\ 1)6V nsoy� Phone No.: Name of Animal Inspector: ..J✓()ll LP�`I`� Town: Signature of Animal Inspector Date: Phone No.: See back side of this form for explanation of Isolation, Strict confinement, close Observation, Exposure by Proximity, Quarantine and Signs of Rabies. I hereby certify that I have read both sides of this document and I agree :o roi_ow the provisions described in it. Signature of Owner or Other Responsible Person Refused to sign, but Order was Issued Animal Inspector please initial if not signed OWNER'S COPY-- , This order is enforceable under MGL Chapter 129; section 21, 330 CMR 4.03 Massachusetts Department of Food and Agriculture 5 3oi�J' Division of Regulatory Services ` Bureau of Animal Health NOTICE OF POSSIBLE EXPOSURE TO RABIES AND QUARANTINE ORDER Your pet may have been exposed to rabies as a result of recent exposure to wildlife or a high -risk domestic animal. If your animal is unvaccinated, you are strongly urged to have it euthanized (unless animal was only exposed by proximity). If you do not, you are hereby ordered to (check appropriate measure): isolate your pet for 3 months, followed by 3 months of strict confinement. Vaccinate the animal 1 month prior to release, and revaccinate between 9 at,d 12 months later, strictly confine your pet for 6 months, and vaccinate the animal 1 month prior to release, and revaccinate between 9 and 12 months later. vaccinate your pet immediately and closely observe the animal for 6 months, revaccinate between 9 and 12 months later. If your animal is currently vaccinated, you are hereby ordered to: vaccinate your pet immediately followed by 3 months strict confinement. vaccinate your pet immediately and closely observe the animal for 3 months. You are to inform your veterinarian immediately of any unusual behavior or change ill the health status of this animal. Any animal which dies for any reason while under quarantine must be submitted for rabies testing. 5ec�.y� 0d— +V._ /�lwwiley . ! Animal was euthanized. DATE OF EXPOSURE: �� r / A n Yr,,l tr fir J Name of Owner: Address: Phone No.: - �J 9- 3e/-,3/ Town: MG. ei iip: Cj C7y'/tT Type of Animal: ! Dog Cat_ Other (specify) / t Name of Animal:YA70-, Breed: -�Jr C') _ Colors: ) ? Age:J3Date of last rabies vaccination prior to exposure: Vaccination Duration: 1 yr_3 yr_ Unknown Date of post exposure vaccination Date of Order of Qua(to be given to current vaccinates only) ra�nti�ne (� Name of Veterinarian: \/,(�(_`r(�-j- Phone No.: Name of Animal Inspect `�L� 11 ��.) 4-,i- Town: Y 1C.�Yl `i�l i�.\ Phone No.: store of Anima Date: Inspector see back side of this form for explanation of Isolation, Strict Confinement, Close Observation, Exposure by Proximity, Quarantine and Signs of Rabies. I hereby certify that I have read botri sides of this document and I agree ,-.o toi_ow the provisions described in it. Signature of Owner or Other Responsible Person Refused to sign, but Order was Issued Animal Inspector please initial if not signed OWNER'S COPY-- , This order is enforceable under MCL Chapter 129; section 21, 330 CMR 4.03.