HomeMy WebLinkAboutRabies - 2000Massachusetts 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 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 under
quarantine must be submitted for rabies testing.
Animal was euthanized.
DATE OF EXPOSURE:
Name of Owner: i J!' r� fi — 'ram(_! l -e� ,v7Phone No.: � 5' - (p �/'�"�
Address: "� [�1% Town: ///�sYJ� L,U'� zip: ®zz ) 9_
Type of Animal: _Dog _ Cat ✓Other (specify)
Name of Animal: �GLjkos Breed:
colors:/'Girt{/ice
Age: Date of last rabies vaccination prior to exposure:(W///4r- Vaccination
Duration: 1 yr_3 yr_ Unknown Date of post exposure vaccination
(to be given to current vaccinates only)
Date of Order of Quarantine
Name of Veterinarian: OV_LT'' Phone No.:
Name of A�niimal Inspector: .` 17- 1 %�"
Townie i// �jff:51 rL.-) Phone No.:_..... e5_v)
Sigf�sqtu��iir��leyy��off �A��n��imal Inspector
Date • 0�/��LC,-c % i _-Z'60 �
i
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 to follow 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.
RABIES
Management of Dogs and Cats Exposed to Wildlife
DEFINITIONS
1.
Isolation
a)
Animal kept from human or animal contact.
b)
Animal to be confined in an appropriate facility, e.g., dog pound,"
veterinary hospital or commercial kennel or quarantine facility for
livestock approved by the Animal Inspector of the appropriate
municipality.
2.
Strict Confinement
a)
Animal may be kept at home in a house, garage or some other escape -
proof building or enclosure approved by the local Animal Inspector.
b)
Animal may be leash -walked under immediate control of an adult.
c)
Owner informed of potential rabies risk and given instructions in
writing.
d)
Owner required to notify veterinarians of unusual behavior or change
in health status of pet.
3.
Close
Observation
a)
Animal may be kept at home and under the supervision of owner or
other responsible person.
b)
owner informed of potential rabies risk.
c)
Owner required to notify veterinarian of unusual behavior or change
in health status or pet.
4.
Exposure
by Proximity - Seen near or in close proximity to confirmed
rabid
animal - no contact or wounds. Dog or cat should be examined by a
veterinarian to assure there are no wounds.
5. Quarantine - Separating a domestic animal from humans and other animals
for the purposes of observing for signs of rabies and minimizing chances
of the animal spreading rabies to humans and other animals. Close
observation, isolation and strict confinement are forms of quarantine.
6. Signs of Rabies - Unexplained aggression, impaired locomotion, varying
degrees of paralysis, extreme depression or viciousness. The signs of
rabies vary in animals. Some will display attack -like behavior while
others appear sick or dazed.
7. For further information, contact the Animal Inspector in your city/town.
/REQUEST FOR RABIES EXANUNATION
State Laboratory Institute, Virology Division
Rabies Laboratory (617) 983-6385, -6386, -6387
r
FOR LAB USE ONLY
Date Received -??
..� 2-.A0
?lab NQ:1 %A..
1?
SUBMITTER In 6t
Agency —Owner or Person Who Found Animal
Street-Q o fh P r k 5 Street
City/State/Zip mf� S City/State2ip M4r� (yt
Phone (503) S 1 — Phane Ibq t 33 I
SPECIMEN INFORMATION (use reverse side for additional information)
ANIMAL SPECIES: c,o Breed _ D l_}1 Age ❑ Petf Stray ❑ Wild ❑ Unknown
Why is animal to be tested?
q Human exposure ❑ Pet exposure tqActing side
Symptoms:
❑ Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivatlon ❑ Seizures Co Heg6L 4Lv, ,,
❑ Unexplained wound ❑ Found dead ❑ Other
A
Cause of death: IRNatural ❑ Killed Method Date ofdeath / 9
o c�
Vaccinated for rabies: []Yes ❑ No '�R3 Unknown Date of vaccination
Travel out of state: ❑ Yes ❑ No WUnknown Where When
Bitten by another animal within 12 months: ❑ Yes ❑ No W Unknown If yes, by what?
In what TOWN was animal found7_MAr�S�� Irk In what
EXPOSURE INFORMATION (use reverse side for additional information)
PERSON(S) EXPOSED:
Name LA, An
Street (� 6,
City/State2ip men SL'o l
Phone (,5cpj _
Type of exposure:
❑ Bite ❑ Scratch ❑ Lick fji) Unknown
® Other _C a k N a y i,An CAL(,
Date of exposure I v
Body site
Severity of exposure
Circumstance of exposure:
❑ Capture 1( Handling ❑ Specimen prep.
❑ Unprovoked attack ❑ Provoked attack
❑ Indirect exposure ❑ Other
Was person previously vaccinated?
. ❑ Yes Q'No ','Unknown
Did person receive rabies shots after incident?
❑ Yes ❑ No 114 Unknown
Physic(an/Hospilal Phone
ANIMAL(S) EXPOSED:
Name rr , 4
Species_ V,91 ino
Owner
Street 5 a
_City/State/Zip 4n c� h S ' n
Phone ( )
Type of exposure:
O Bite ❑ Scratch ❑ Lick 14 Unknown
cZ Other
Date of exposure
Circumstances of exposure:
❑ Fight ❑ Vicinity ❑ Dead animal contact
tkOther
Was animal's rabies vaccination up -to date?
❑ Yes ❑ No allnknown
Did animal receive rabies booster after incident?
❑ Yes allo ❑ Unknown
ARL/B BOOK !/�O
,REQUEST FOR RABIES EXAMINATION
State Laboratory Institute, Virology Division
Rabies Laboratory (617) 983-6385, d387
SUBMITTER Animal Rescue League of Boston
Agency (tnarantine nanartmant Owner or Person Who found Animal
Street 10 Chandler Street Street
City/State/Zip Boston, MA 02116 City/State/Zip
Phone �17 ) 426-9170 ext. 113 or 110 Phone( )
SPECIMEN INFORMATION (use reverse side for additb al Information)
ANIMAL SPECIES: e- �� Breed IAgeJ -' Pet ❑ Stray ❑ Wild ❑ Unknown
Why is animal to be tested? Human exposure ❑ Pet exposure ❑ Acting sick
Sympt
Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Selzures
❑ Unexplained wound ❑ Found dead q Other
Cause of death: ❑ Natural Killgd' Method / lus Date of death
Vaccinated for rabies: ❑ Yes WNo 11JJnknown Date of vaccination
Travel out of state: ❑ Yes ❑ No dE1 Unknown Where When
Bitten by another animal within 12 months: ❑ Yes ❑ No nknown If yes, by what?
In what TOWN was animal IgWW? Nt AM NS -(, elal In what;_VR=7 I v, s t-dL
EXPOSURE INFORMATION (use reverse side for additional information)
PERSON(S) EXPOSED•
Name /tnJy;2,1 'RunT`4-5
Street. ':3 /- Z-.,j
City/State/2ip Fz & 144-
Phone(-404y) 339-6�91
Type sure:
Bite ❑ Scratch ❑ Lick ❑ Unknown
❑ Other
Date of exposure
Body site
Severity of exposure Mcd�rnv�
Circumstance of exposure:
❑ Capture andling ❑ Specimen prep.
❑ Unprovoked attack ❑ Provoked attack
❑ Indirect exposure ❑ Other
Was person previously vaoci ?
❑ Yea ❑ No BfUnknown
Did person receive rabies ah er Incident?
❑ Yes ❑ No <11 Unknown
Physlcian/Hospital Phone
ANIMAL(S) EXPOSED:
Name
Species
Owner
Street
City/Slate/Zp
Phone ( )
Type of exposure:
❑ Bite ❑ Scratch
❑ Other
❑ Lick ❑ Unknown
Date of exposure
Circumstances of exposure:
❑ Fight ❑ Vicinity ❑ Dead animal contact
❑ Other
Was animal's rabies vaccination up-to-date?
❑ Yes ❑ No ❑ Unknown
❑ Yes ❑ No ❑ Unknown
REQUEST FOR RABIES EXAMINATION
State Laboratory Institute, Virology Division
Rabies Laboratory (617) 983-6385,-6386,-6387
FOR:LAB USE ONLY
Date Received:
!Lab No: �L I
Agency TrQ�,s enV <,g x'troc wnerorPersonWhoFoundAnimal Yei�n Zy-< e5
Street gA2l\nit�� S� Sreet_ $3 :Souk 5'--
City/Slate/Zipj �jDcAn ,� C'1__at i Clty/State2!p_Mari-�-)P)d yy�)a gaagN
Phone (50S) Co ,4 - !iy,32y Phongj-oFS) �53 9 —o76) V
SPECIMEN INFORA]ATION (use reverse side for additional Information)
ANIMAL SPECIES; hCi I Breed To�rv�n�t��J Age id Pet ❑ Stray ❑ Wild ❑ Unknown
Why is animal to be tested? tR Human exposure ❑ Pet exposure ❑ Acting sick
Symptoms:
*ggress!on ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures
❑ Unexplained wound ❑ Found dead ❑ Other
Cause of death: ❑Nat! ra! 49 K.II!ed Method i�evy y�ca Date of death_ 151,
Vaccinated for rabies: M Yes ❑ No ❑ Unknown Date of vaccination ,Dq
Travel out of state: ❑ Yes RNo ❑ Unknown IWhere When
Bitten by another animal within 12 months: ❑ Yes El No ❑ Unknown if yes, by what?
In what TOWN was animal found? /tiw.� s ('• rz Lc� In what COUNTY?
EXPOSURE INFORMATION (use reverse side for additional information)
PERSON(S) EXPOSED:
Name 3
Street S�`3
City/Slater7ip rk� (� o ao 119
Phone(�g) 3vq -O?�
Type of exposure:
0 Bite ❑ Scratch
❑ Other
❑ Lick ❑ Unknown
Date of exposure
Body site $Zlc: e
Severity of exposure 3(�
Circumstance of exposure:
❑ Capture ❑ Handling ❑ Specimen prep.
❑'Unprovoked attack i&Provoked attack
❑ Indirect exposure ❑ Other
Was person previously vaccinated?
y
❑ Yes No ❑ Unknown
Did person receive rabies shots after incident?
❑ Yes RlNo ❑ Unknown
ANIMAL(S) EXPOSED:
Name
Spaces
Cwlet _
Street
Citv1State0p
Phone ( )
Type of exposure:
❑ Bite ❑ Scratch ❑ Lick ❑ Unknown
❑ Other
Date of exposure
Circumstances of exposure:
❑ Fight ❑ Vicinity ❑ Dead animal contact
❑ Other
Was animal's rabies vaccination up-to-date?
❑ Yes ❑ No ❑ Unknown
Did animal receive rabies booster after incident?
❑ Yes ❑ No ❑ Unknown
4-Lmo
i f v YOOC ahct agriculture
Of Animal -Alth
"Ias9achL;3Cttu Departtaeht of Pu*�li.c Health
Diva ---ion of Epidemiology
"OTiCE O7"-'O'SS13_T,E E$POsURE TO R11,.EIES
You:: pet may have bee; eX' osed to
exposure tc wildlife o: a i�,,._; rabies as a result o recent
ir.:a nvaccinato you are a --_sk do.«estic ar, 1. If your ,
c;.91,v urged to t
�.} r `t IC• -, Ra;�' i-Uthanrsed. if i"ou do no -
you are here.o; c_de�ed ;,-,
ec;': 4ppropria te neasure) :
isolate your pet for 3 ^oaths, followed �>
ccnl-'nC+i nn= i ^d VaCCI } 3 nonths Of St
nate• the animal l �'
,i pr or r
o ele
o,. f�
.Sti-Ceti}' c.n_.�iA i_e Yoini Pct r'Jr 6 nion1ths� and vaccinate the c...
<:� .Gl
In
prior tc) relese 1
.Lf your c. it ii^,ai i5 .. �. n?- ;ZLiy -;'a Cci nated, -7Cu are hereby Orders—d
vaccinate your net A.inediately followed b y 3 months S t-r Ct rCn f i ;+n;?lent
_\'onthc ate },our pet ?. h.:i:leQlate-17 grid closely Observe the an i::,a' {Or
:;cr,th 3
You are to ihforl your vetorinarian immediately o
hehavior or to
e health any u^,usual
4 in the status -of this animal.
arae of Owner: �i� ��1`1
nn Phone No.:$3�_���
:address:
--- " "1 ---- --- Town:
Tvoe Of Anllilai
l
Do. \ ru
g Other (sSeClflj
;dame of ar,ima:1 :
Breed --�-`
_ Colors:
`. Date of �ast es r% `C
`'b vacs nation: Date of booster:
(if gi.vcn)
Vane of veterinarian:• 14as
—`___---- Phone r;o.
Name of Aninal Co, trol Oific;.al: C6 L4c
Phone No.
Signature of Animal Ccntro]_ Official:
Send 1 COb}' C 8 I; to the
i`.
Pleir. MA 0?13 _s on. c Epide ;iolory 305 South Stree,-
:Er.. - -'v/ and �G %r.e ._ivisio:n ` -,. ` -I �a;;,a_Ca
al Health, 100
Floor ?_1, r C27.O2 Cain' =c'2
J v.0 J. a 11('.
u
s
e
REQUEST FOR RABIES EXAMINATION FOR:LAB U5E. ONLY
State Laboratory Institute, Virology Division Date Reoeivatl �C7 (ICJ Izr�
Rabies Laboratory (617) 983-6385, -6386, -6387
SUBMITTER y L'C°;
Agency �—- — Owner r Person Who Found Animal b i e �e �2ViC
Street P` C
City/Slala/Zip f ��i ^l ti Lf i/d Clly/SlalelZi' /Ll� 1 Ste/ f /c: /i
Phone (ZF) .SAC) — ZS! ° yPhone (.5'D,P) a (v I — .9 r, L/6
SPECIMEN INFORMA ION (usa mverse skis for additional Information)
ANIMAL SPECIES: ."✓Y Broad DL 14_ Age'
t�(Pet ❑ Stray ❑ Wild O Unknown
Why Is animal to be tested? gHuman exposure ❑ Pat exposure O Acting sick
Symptoms:
O Aggrossion IkAtaxia t�'bt8066ntatIon X(efhargy ❑ Paralysis ❑ Salivation O Seizures
❑ Unexplained wound ❑ Found dead ❑ Other •2---e--
Cause of death: ❑ Natural OrKliled Method 2 e C S kvegcu ,,. I I/ Date of death ( U12k'� pG
Vaccinated for rabies: ❑ Yes �6o ❑ Unknown Date of vaccinatiotl
Travel out of state: Dyes IQ No '4 nknown Where When _
Bitten by another animal within 12 months: xl�yss O No ❑ Unknown If yes, by what?
In wha( TOWN was animal [=d? Yylav)C f-_' lA In what COUNTY? I?( <
EXPOSURE INFORMATION (use reverse side for additional information)
PERSON(S) EXPOSED:
Name IDbblc
Street o \r-\C t-. S}
city/Stale/zip _l1 la nC l t t1 1,� L20y�
Phone(5-Cf) QLv t --Pb Y6
Type of exposure:
O Bile kScmlch ❑ Lick ❑ Unknown
❑ Other
Dale of ox s re I b (� k o Inc
Body site (k,� yy-\ 9—
Seventy of exposure
Circumstance of expos re:
❑ Capture Handling ❑ Specimen prep.
O Unprovoked attack ❑ Provoked attad
❑ Indirect exposure ❑ Other
Was person proyloVsly vaccinated?
❑ Yes,KNo ❑ Unknown
Did person recerverablas shots after Incident?
❑ Yes XNo ❑ Unknown
Physician/Hospflal Phone
ANIMAL(S) EXPOSED:
Name
Species
Owner
Street
City/Slala2p _
Phone ( ) _
Typo of exposure:
❑ Bite O Scratch ❑ Lick ❑ Unknown
O Other
Date'of exposure
Circums(ances of exposure:
❑ Fight O Vicinity ❑ Dead animal contact
❑ Other
Was animal's rabies vaccination up-to-date?
O Yes ❑ No ❑ Unknown
Did animal receive rabies booster after Incident?
❑ Yes ❑ No ❑ Unknown
LABORATORY RESULTS'- FLUORESCENTRABIES ANTIBODY TEST Teet.Date
POSITIVE (RABID) ❑ NEGATIVE (NOT RABID), SPECIMEN UNSATISFACTORY ❑
COMMENTS: j)G,I 1tl/30 CV j�, L
zuL
0
N
L
Y
Ups
REQUEST FOR RABIESTDiv
ATIOIV FOR:LAB U5E. ONLY
State Laboratory Iastitntc, VirologData Reeeivad
Rubies Laboratory (617) 983 638597 Lnb No �00
Agency IfyiLt Owno or Person Who found Animal to rlo 1)u mA I1 t f7
Slrael�l5 �tMal
Smet '"11AU2�f`P t2
City(slalerzdt��w u `� City/State/Zip mn�{�010 rnA t�a�y
Phone (�8) 580- 51, Phone(3-6fj_3�f/-35(p`�
SPECIMEN INFORMATION (use reverse aloe for additional Information)'
ANIMAL SPECIES: C L1Y)11 c Breed ,RIB ) ( iEVYt o Y Age Y'',l kPat ❑ Stray ❑ Wild ❑ Unknown
Why Is animal to be tested?-d,Human exposure ❑ Pet exposure ❑ Acing side
Symptoms:
❑ Aggrosaion ❑ Ataxia ❑ Dlsorientallon ❑ Lelha gy ❑ Pamlyais ❑ Salivation ❑ Seizures
❑ Unexplained wound ❑ Found dead Other 0.1 h
Cause of death: ❑ Natural CkKllled Melhod )OhO.\ Wl 4C Cy� Date of death \\ rj
Vaccinated for rabies: S5.Yes ❑ No ❑ Unknown Dale of vaccina6onM j j) 1%-1 (3klr vac(% kr4J
Travel out of state: ❑ Yea ❑ No 1iUnknown Whore '' When
Bittan by another animal within 12 months: ❑ Ye ❑ �!o Unknown If yes, by what?
In what TOWN was animal (gya7' _ice Q� i ( In what BOUNTY? _ <
EXPOSURE INFORMATION (use reverse side for additional information)
PERSON(S) EXPOSED: ,
Name 1 cl,urm H¢vaillL
Street 5�15 W.�enldr t
City/State/Zip Uf.g✓ tua�rlvnyg
Phone (QjB) 5�0 -a 515
Typo of exposure:
Mite ❑ Scratch ❑ Lick ❑ Unknown
❑ Other
Date of exposure I I I �,- OU
Body site Mtn do k(?, A—IR,/�(l
Severity of exmosure 'mi ((d
Circumstance of exposure:
❑ Capture dandling ❑ Specimen prop.
❑ Unprovoked attack ❑ Provokod attack
❑ Indirect exposure ❑ Other
Was person previously vaccinated?
Yes ❑ No ❑ Unknown
ANIMAL(S) EXPOSED:
Name
Species
Owner
Street
oily%Slaleop
Phone ( j
Typo of exposure:
❑ Bile ❑ Scratch ❑ Lick ❑ Unknown
❑ Other
Date of exposure
Circumstances of exposure:
❑ Fight ❑ Vicinity ❑ Dead animal contact
❑ Other
Was animal's rabies vaccination up-4o-da1a7
❑ Yes ❑ No ❑ Unknown
Did animal receive rabies booster attar Incident?
Dld person receive rabies shots after incident? �mDY` ❑ Yes ❑ No ❑ Unknown
❑ Yes PNo ❑ Unknown '� ('t>
PhysUan/Hospital Phone TA6
L
L
A LABORATORY RESULTS - f LUORESCENT.RABIESANTIBODYTEST Toot.Data
u POSITIVE (RABID) ❑ NEGATIVE (NOTRABID) SPECIMEN UNSATISFACTORY ❑
e COMMENTS: 011 04L k, .
0
N
L
REQUEST FOR RABIES EX. MENATION
State Laboratory Institute, Virology Division
Rabies Laboratory (6t7) 9831385, -6387
C _
FOR LA&USE: ONLY
Dates Received:
Lab No:,x46)U
SUBrtitITTER o .J ,o�`�/< SY /
Agency bu, ,I�( 0o /I / Owner or Person Who Found Animal Lrso
Street OJrFsr/_ Street /60/ we TsT /�1uiYit�y
City/State2ipjmv„��/� /�1i/ ozcy.Y —i3z f City/State/Zip 6�7r�rFiei� �/ 02vcyf —iI2 r
Phone (�cy)_ 7G/-73oe
Phone(j�-g) 239— Xyy9
SPECTYIEN LYFORIN ATION (use reverse side for additional information)
ANIMAL SPECIES: Breed 01// Age l� ❑ Pet ❑ Stray PWild ❑ Unknown
Why is animal to be tested? 'Human exposure ❑ Pet exposure ❑ Acting sick
Symptoms:
''Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation Cl Seizures
❑ Unexplained wound ❑ Found dead ❑ Other
Cause of death: ❑ Natural A Killed Method_Zet4 /y _vim. .j pate of death /2 7-9 do
Vaccinated for rabies: ❑ Yes ❑ No Unknown Date of vaccination .
Travel out of state: ❑ Yes ❑ No XUrknown Where When
Bitten by another animal within 12 months: ❑ Yes ❑ No N Unknown If yes, by what?
In what TOWN was animal found? %%rN_r�i6 _f' In what ?
EXPOSURE INFORMATION (use reverse side for additional information)
PERSON(S) EXPOSED:
Name 11S4 A-64A2AY
Street /�
City/Stale/Zrp,�ir/P
Phone _3 3 5 — k,y9
Type of exposure:
gBile ❑ Scratch ❑ Lick ❑ Unknown
❑ Other _
Date of exposure x 2 2_7 0O
Body site
Seventy of exposure
Circumstance of exposure: '
❑ Capture AHandling ❑ Specimen prep.
❑ Unprovoked attack ❑ Provoked attack
❑ Indirect exposure ❑ Other
Was person previously vaccinated?
❑ Yes No ❑ Unknown
t7id person receive rabies shots after incident?
❑ Yes KNo ❑ Unknown
Physician/Hospital Phone
AYIMAL(S) EXPOSED:
Name
Species —
Owner
5`ireet
Ci(y/State/Zip
Phone ( )
Type of exposure:
❑ Site ❑ Sc. aten ❑ Lick ❑ Unknown
❑ Other
Date of exposure
Circumstances of exposure:
❑ Fight ❑ Vicinity ❑ Dead animal contact
❑ Other
Was animal's rabies vaccination up-to-date?
Cl Yes ❑ No ❑ Unknown
Did animal receive rabies booster after incident?
❑ Yes ❑ No ❑Unknown
LABORATORY RESULTS`- FLUORESCENT RABIES ANTIBODY TEST Test Date
POSITNE:(RASID) ❑ NEGATIVE (NOT RABID) )X SPECIMEN UNSATISFACTORY ❑
COMMENTS: Do "J'A Y i 1