Loading...
HomeMy WebLinkAboutRabies - 2001ARL/B BOOK it'`t011� / REQUEST FOR RABIES EXANUNATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 SUBMITTER Animal Rescue League of Boston Agency _jtnarantine Department Street 10 Chandler Street City/State/Zip Boston, MA 02116 Phone fl7 ) 426-9170 ext. 113 or 110 FOR, LAB USE ONLY Date Received: ?�',3�) Lab No:vo r Owner or Person Who ound Animal �r r r Street -1 L)k)c 1,S City/State/Zip oYMS tii. 07 OH Phone( 5c8) r0fo I - K � i n5 SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: F Breed �- Age' Erl5et ❑ Stray ❑ Wikf ❑ Unknown Why is animal to be tested? w4uman exposure ❑ Pet exposure ❑ Acting sick Sympt9ms: ITAggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ F99und dead ❑ Other Cause of death: ❑ Naturaj Riled Method ..Z V =FO AEG )Sq,Date of death 3 - // - o L Vaccinated for rabies: ❑"Yes ❑ No ❑ Unknown Date of vaccination Lk �,J rNcd Travel out of state: ❑ Yes I,7-No ❑ Unknown �WhereWhen Bitten by another animal within 12 months: Yes tn'No ❑ Unknown If yes, by what? In what I= was animal (gyad? In what COUNTY?yc c o L, EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street city/StateOp MA oZLq� Phone (Scg) c-Q (01 — ( 3O C, Type of exposure: ❑ Bite eSScratch ❑ Lids ❑ Unknown O Other Date of exposure 3 -!/ - d i Bodysite Severity of exposure Circumstance of exposure: ❑ Capture b<andling ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes E(No ❑ Unknown Did person receive ables shots after incident? ❑ Yes MNo ❑ Unknown Physidan/hlospital fAn MP_ Phone ANIMALS) EXPOSED: Name Species Owner street City/State/Tp 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 Did animal receive rabies Ooster after incident? ❑ Yes ❑ No ❑ Unknown Y REQUEST FOR RABIES E<Y.AMENAUON State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 SUBMIT -TER FOR LASUSE:ONLY I Date: Received: �' V5 (Of Lab No:: , 5r3>� Agency Owner or Person Who Found Animal '� Street _0 IA✓ fsST 97— Street s Z �c i'% rT City/State0p �/4�r<ir/d'� /�/� 02cYC Cily/State/Zip_/�/.r Phone (�bY) _ 2o/ 2 2oc Phone 7 j o SPECIMEN INFORMATION (use reverse side for additional informa(ion) ANIMAL SPECIES: /21xccw..I Breed Age 1-2,", ❑ pet Why is animal to be tested? '*uman exposure ❑ Pet exposure ❑ Acting sick " Sm Id ❑ Stray . Wild ❑ Unknown y p ms. t<Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural � Killed Method S/^ o% Date of death Y' 3 c / Vaccinated for rabies: ❑ Yes ❑ No XUnknown Oate of vaccinat on Travel out of state: ❑ Yes ❑ No .cif Unknown Where When 8iden by another animal within 12 months: ❑ Yes ❑ No XUnknown If yes, by what? In what T M was animal found? In what G9C ? /1.i.r� EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name DA L'T -j t/.r11( e rer Street 27 .S,:7 /1{' City/State/Zap Phone (.-4 3/ 3 22 �V/l'4il `C/�N�JT�F r.✓LII Type of exposure: k8ite ❑Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure Y12 0 / Body site Zc,, Severity of exposure Circumstance of expos re: ❑ Capture ❑ Handling ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes K No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes ){ No ❑ Unknown Physician/Hospital Phone ANIMAL(S) EXPOSED: Name• Species Owner �treel City/State/Zip Phone.( ) Type of exposure: ❑ Bite ❑ 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 n LABORATORY RESULTS- FLUORESCENT RABIE.S:ANT1800.Y'TEST Test Date a POSITNE:(RABID)�(1 NEGATIVE (NOT' RABID) Q SPECIMEN UNSATISFACTORY ❑ E COMMENTS: ��\��1. y C J The Commonwealth of Massachusetts Executive Office of Health and Human Services 3 7' Department of Public Health State Laboratory Institute 4 gy0y` 305 South Street, Jamaica Plain, MA 02130 ARGEO PAUL CELLUCCI (617) 983-6200 GOVERNOR JANE SWIFT LIEUTENANT GOVERNOR WIILIAM D. OTEARY SECRETARY Rabies Laboratory, ext. 6385 HOWARD K. KOH, MD, MPH COMMISSIONER 04/05/2001 Attn: Mansfield Board of Health Lab Number: RA01-0538 Animal: Raccoon Found in: Mansfield Submitted by: Mansfield Animal Control Mansfield 508-261-73001 Test Date: 04/05/2001 Result: POSITIVE Exposure information: Human exposure Dalton Wells Mansfield 508-339-1422 Comments: If you are aware of any additional exposures, or have any corrections to this report, please call the above number. �a 4'j nonro�.u�s��.�r "OVALL6"J" Qz r000 anG AgrlculLure Division of Animal Health Massachusetts Department of public Health Division of Epidemiology NOTICE Or POSSIBLE EXPOSURE To RUBIES 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. 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, and vaccinate the animal 1 month prior .to release. strictly confine your pet for 6 months, and vaccinate the animal 1 month prior to release 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. �v� Name of Owner: QePf�O/' �i( e( `��( Phone No.:,L��` Address: Town: r ) zip: Type of Animal: Dog Cat _, Other (specify) Name of animal: Breed: Colors: 2WL&io,2 / Age: Date of last rabies vaccination: 4096 �7 Date of booster: / (if given) Name of veterinarian:� Phone Name of Animal Control Official: e Phone No.: Town:!Y� 1 Signature of Animal Control Official: Date: Send 1 copy each to the Division of Epidemiology, 305 South Street, Jamaica Plain, MA 02130, and to the Division of Animal Health, 100 Cambridge Street - Floor 21, Boston, MA 02202 REQUEST FOR RABIES EXAMINATION State Laboratory Institute, Virology Division Rabies Laboratory; (617) 522-3700, x194/196 SUBMMT,R /� ^ ` / Uri / i 3 lZZe ✓' Agency N�a : we o d /* s P. Owner or Person Who Found Animal Oa �Cw Street el 3 1 ur Street /6 2 /V. /I/„,'K sa- City/8tate2io z City/State2ip Al f- e 26yq, Phone ( 787 76 I/ ' 3 a i i Phone ( 7611 ) _ HY6 - n v T Ge./l 6 1 -7 - 3 -7 SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: Ce,-1- Breed Q S F)" Age ? ❑ Pet la7 stray ❑Wild ❑ Unknown Why is animal to be tested? Human exposure ❑ Pet exposure ❑ Acting sick Symptoms: -- — — rgysl�/e. ❑ Aggression ❑ Ataxia Cl Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural Zilled Method e.wf6e.. ,,.,fin Date of death Vaccinated for rabies: ❑ Yes []�No ❑ Unknown Date of vaccination Travel out of state: ❑ Yes ❑ No Mnknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No l�kiJnknown If yes, by what? In what TOWN was animal fond? A14 s fle /d In what COUNTY? �a szat, EXPOSURE INFORMATION (use reverse side for additional information) {{��(S�EXi PERSONSED v w / y ANIMALS) EXPOSED: Name Gr dv 13adhu dd, /#- ;,�Z/rleI Name Street see ., 6a v e-- Species City/State/Zip Owner Phone ( ) Street Type of exposure: City/State/Zip ❑ Bite ❑ Scratch ❑ Lick it' lnknown Phone ( ) ❑ Other Date of exposure kj� ee w Body site !mot N e, Severity of exposure YLh t" w._ Circumstance of exposure: ❑ Capture ❑ Handling ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person pre�v}i,ou,sly vaccinated? ❑ Yes' Rlo ❑ Unknown Did person receive rabies shots after incident? ❑ Yes ❑ No ❑ Unknown Physician/Hospital 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 _.._ —_ .. —.. ..,_.�:.:_.......> F i e..-e>�a.�s...5::_ z ^'�- r ac ATTACHMENT 9 REQUEST FOR RABIES EXAMINATION Center for Laboratories and Communicable Disease Control Rabies Laboratory (617) 522.3700 FOR LAB USE ONLY Date Received: "q -0,27--7> Lab No.: (214-7 I Agency KAA%C(� L.1 AN (MhL N �Nl�u� Owner Person L A- P7 p 0 I I � Submitting Who Fou"��l��n�im�al Street 2) WSS71 SStreet Fc� t (� CiD'N� �I 12V✓ `L CIty,State M/ p�")ss ti��R YI/lt� City -State `AAA h'NSFI L (`J) �fI+� Zip OZO T O Phoneg6t�_ 2G ( 7-�0o Zip �i cif ttT— Phone S� � 33_f I\ ANIMAL SUBMITTED ANIMAL: ""�� Breed Age_._. Pet❑ Stray❑ Wild© Unknown❑ Neurologic or behaviorai�signs observed during period 1 week before thru 10 days after biting incident: Describe: Cause of Death: Natural[] . Killed❑ I Method Date and Time of Death Vaccinated for Rabies: Unknown[] No❑ Yes❑ Type of Vaccine _ Date Travel Out of State: Unknown❑ No❑ Yes❑ Where When Bitten by an other animal within 12 months: Unknown❑ No❑ Yes❑ Species of Biter Date: C,tyrTown animal was found or collected: ANIMAL(S) BITTEN BY SUBMITTED ANIMAL: Animal's Name: Species: Date of ress Vaccinated for Rabies: Tel. PERSON(s) BITTEN PERSON(S) BITTEN BY SUBMITTED ANIMAL: If more than one person has been bitten, please / O Include the same information for each additional Name I�� M1NCrJ /" S person on the reverse side. Street " '"�1^/t"S�^6 � � � i r��� Was bite provoked? Unknown❑ NO❑ Yes City/State/Zip r Y 1 `��U� Site. of Bite: , Phone: Date of Bite Severity of Bite:. Was Victim Treated? Unknown❑ No❑ Yes❑ Town where bite occurred If YES, give name, address & Tel. No. of attending physician, clinic and vaccinations received: NOTE: Local Health Dept. should be notified of all animal bites. ( Use reverse side for additional Information on specimen and/or biting episode ) LABORATORY RESULTS -FLUORESCENT RABIES ANTIBODY (FRA): b U 1 c O m UNSATISFACTORY ❑ n NEGATIVE (Not Rabid) 0 m POSITIVE (RABID) ❑ 0 10 Comments: J O LL Rev 1192 RTO - REQUEST FOR RABIES EXANM fATION State Laboratory Institute, Virology Division Rabies Laboratory (6I7) 983-6385, -6387 FOR LA&USE::ONLY Date. Received: liv- a- 6 Lab.Nb::.61 auoivui I Lp, /Ow.Ij of /- /"/r s arm. Agency rr6 0 Fni cl)-L Owner or Person Who Found Animal h6 /s /Z<����� Street S'o ,uc-9 �/ S7. Street_ /6 2 L si si, City/State2lp lam/ r/r�'/oP, IV4 020yb' City/State/Zip. „vr�.JP do 6zoy�-/ Zr Phone(pY) _Gl- -23ov Phone(sti5) 335e- 9352 SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: S' �� Breed Age Syr ❑ Pet ❑ Stray )4Wild ❑ Unknown Why is animal to be tested? ❑ Human exposure pet exposure ❑ Acting sick Symptoms: Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural )NKilled Method S d ,7- Date of death Vaccinated for rabies: ❑ Yes ❑ No f$( Unknown Date of vaccination Travel out of state: Cl Yes ❑ No at'Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No `Unknown if yes, by what? In what LQ was animal Lund? f�/A^l/>dlcQ In what ? 4(''s—le/ EXPOS�J INFORMATION (use reverse side for additional information) PERSONS) EXPOSED: ANIMAL(S) EXPOSED: Name Name S1A/I4CJ_ // 21 Street Species �a ✓. v�r Cily/State/Zlp Owner ^/ir, Phone ( ) street - _ ZP z cry rT Type of exposure: City/State/Zip 6.ri //n dz°yd ❑ site ❑ Scratch ❑ Lick ❑ Unknown . Phone (may) ❑ Other Type of exposure: Date of exposure ❑ Bite ❑ Scratch ❑ Lick jZ Unknown Body site .Other Sjovy 94 sa/✓9 Severity of exposure Date of exposure 912 z a/ Circumstance of exposure: Circumstances of ex osure: of ❑ Capture ❑ Handling' ❑ Specimen prep. ❑ Fight ❑ Dead animal contact ❑ Unprovoked attack ❑ Provoked attack ❑ Other ❑ Indirect exposure ❑ Other Was animal's rabies vaccination up-to-date? Was person previously vaccinated?iXes ❑ No ❑Unknown ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? Did person receive rabies shots after incident? ❑ Yes ❑ No ,Unknown ❑ Yes ❑ No ❑ Unknown Phy§ician/Hospital Phone L. LABORATORY RESULTS' • FLUORESCENT RABIES.'ANTIBOD.Y"TEST Test Date D :;�,' -b A a u POSITIVE:(RABID) ❑ NE'GATIVE'(NOTRABID)d� SPECIMEN UNSATISFACTORY ❑ E COMMENTS; o Nd 0 y REQUEST FOR RABIES EXAINMNATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 SUBtAI•TTER FOR LAaUSE::ONLY Date, Received: [0 Lab:. No:: Z� Agency Owner or Person Who, Found Animal -%�%'T �%/—'� Street f'a i O JS 7 s T Street y v ✓� ✓ S' City/State0p City/Stateilip Phone (fig) Phone SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: Breed OS'14'� Aged ❑ Pet O§tray ❑ Wild ❑ Unknown Why is animal to be tested? ,'Human exposure ❑ Pet exposure ❑ Acting sick Symptoms: aggression ❑ Ataxia Cl Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural �IKilled Method Le �� ,w %e % : Date of death Vaccinated for rabies: ❑ Yes ❑ No ,Unknown Date of vaccination Travel out of state: ❑ Yes ❑ No Unknown Where When _ Bitten by another animal within 12 months: ❑ Yes , ❑ No Unknown If yes, by what? In what TOWN was animal fg_un. ? _�7r,✓rF.�f/�P /In\what ? &L/, EXPOSVRE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name ✓/��� S C��%s Street c/ City/State/Ztp /v/Ar.✓ri,/Z- /L1a oze,y"p Phone(5-oP) 2 Type of exposure: ❑ Site Xscratch ❑ Lick ❑ Unknown ❑ Other Date of exposure /o ei A, Body site crr Severity of exposure s Li v u? Z Circumstance of exposure: ❑ Capture ❑ Handling ' ❑ Specimen prep. )2�bnprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? gYes ❑ No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes 9No ❑ Unknown Physician/Hospital Phone ANIMALS) EXPOSED: Name Species Owner 4el City/State/Zip Phone ( ) Type of exposure: ❑ Site ❑ 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 LABORATORY RESULTS' -• FLUORESCENT RABIE.Spp:,,ANTIBOOY'TES.T Test Date I U POSITIVE. (RABID) Q NEGATIVE (NOT'RASID).SPECIMEN UNSATISFACTORY ❑ COMMENTS: / REQUEST FOR RABIES E.YAl-YEENATION State Laboratory Institute, Virology Division Rabies Laboratory (6t7) 983-6385, -6387 S UMMITTER FOR LAB<USE:ONLY `� I Date: Received: Lab No:. C I Agency �/�.«/ Ca•� r> / Owner or Person Who Found Animal L/S. a Street Street /661 Cily/State2ip iLv NrFir/.P G*�4 oLoyr CitylStatelZip y�r �L �r'rtf o�. y� ?hone (� y) z�/— 73o o 7 y Phone (soe) 73 s- vv s5 SPECIMEN INFO TTON (use reverse side for additional information) ANIMAL SPECIES: Breed /)Sh' Age j « J-f ❑ Pet ❑ Stray 6T Wild ❑ Unknown Why is animal to be tested? Human exposure ❑ Pet exposure ❑ Acting sick i Symptoms: M^Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other �o Cause of death: ❑ Natural O Killed Method /_ T7�/1 �,�K Oate of death Z272-77ao �r Vaccinated for rabies: ❑ Yes ❑ No Unknown Date of vaccination Travel out of state: ❑ Yes ❑ No C�(Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No RUnknown If yes, by what? In what TOWN was animal tQmnd? 7 "r/ /P In what COUNTY? �,,• / EXPOS'( INFORMATION (use reverse side for additional information) PERSONS) EXPOSED: Name Street City/State/74 y� .�uf/�ti a p>u V.V Phone (Soe ) s s- 9>1199 Type of exposure: "Bite ❑Scratch ❑ Lick ❑ Unknown Cl Other. Oate of exposure i2 At ao Body site i oaf �iN�6n Severity of exposure Orate a)v 6 Circumstance of exposure: ❑ Capture Handling ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes ,A No ❑ Unknown Old person receive rabies shots after incident? ❑ Yes K No ❑ Unknown Physician/Hospital Phone AMNLAL(S) EXPOSED: Name. Species Owner 3lreet City/State/Zip 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 LABORATORY RESULTS - FLUORESCENT RABIES :ANTIBODY 'TEST Test Date —L—Z POSITNE:(RA8ID) ❑ NEGATIVE- (NOT 'RABID) �SPECIMEN UNSATISFACTORY ❑ COMMENTS: FI?o7.-C 1-1 - �— �✓