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HomeMy WebLinkAboutRabies - 2002u a e 0 N L y REQUEST FOR RALLIES EXAMINATION Slate Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6386, •6387 SUBMITPEIt Agency Street.' c City/Slolo/Zlp U Phone FOR LAB.,USE ONLY Lab}No ().. 7a7 1�r Pomon Who Fot nd Anirma CltylSlalo/Zip Phone (CJD�(} ? S� ( SPECIMEN INFORMATION (use rovame side for additional Infonna(lon) ANIMAL_ SPECIES: FF I t cue/ Breed L�- t� Ago I % CC(Po( U Shny ❑ Wild ElUnknomt Why Is animal to be tested? E HUman expoaure ❑ Pet exposure U Acting skik S ymptoms, U Aggression U Ataxia ❑ Dlaorlentallon U l_othorgy U I'aralynis U Salivation L]Solzuros U Unxpl ealnod wound L7 Found dond G Other Cause of death: La'Natural ❑ K�I.Ilo✓d Mothm Vaccinated for rabies: ❑ Yes �O Li L known __ Dale of vaocirtnikm Travel out of stato: L] Yes ❑ No 6LUnknown Whom ' _ When E3itlen by another anhnnl wllhhr 12 months: U Yen U No Inknown It yes, by what? _- In what ZS2�1� was anhnnl (iJy�? iv . ,✓ s�g�--- hr what i „� ----- EXPOSURE INFORMATION fuse roverso si(lo for additional inforrnntion) PERSON(S) EXPOSED: 14 Strool -_S P1eXrr rCSr- yR.1Ve _— City/Slalu/Zip r�2 c��ct CliiR_ rip ���3 L Phone Typo of exposure: H'81(o ❑ Scratch ❑ Lick U Unknown ❑ Other Dale of exposulla-- Uodyslle LPG c llr (r,ao Severity of exposure Sn r<Xz Cln;umstal1w of exposure: U Captran t"andlIng ❑ Spechnen prop ❑ Unprovoked attack U Provoked attack U Induct e4msuro LI Other _ Was poison prevlousfy vaccinated? Lu Yes ❑ No U Unknown Did poison receive rabies snots after Incident? U Yes &No U Unknown Physician✓I IospAal — Phony ANIMAL(S) EXPOSEI) Nanro Spec;des ----- Ownor — --- Slreul Cily/Slalo/Zip _ Phcxio ( ) ---- — Type of exposure: Me ❑ Scratch . ❑ Licit ❑ Olhor Oato of exposure Clrcinnstances of exposure: LI Fight U Vicinity U Other U Unknown U Dead animal contact Was animal's rabies vaccnallon up-to-date? U Yes U No U LJnknomi Did animal receive rabion booster after Incident? ❑ Yos ❑ No U Unkrromr LABORATORY RESULTS - FLubRESCENT RABIES ANTIBODY TEST r POSITIVE (RABID) ❑ NEGATIVE (NOT RABID). SPECIMEN UNSATISFACTORY ❑ COMMENTS: A N, IE-- ,,, REQUEST FOR RABIES EXAMINATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 SUBMITTE br •, r �' /�%i• r�.�f�� Agency Owner or Person Who Found Animal>✓ ✓ L✓� Street C o < r T Street - / Z Of it : -r W. City/State/Zip f- City/State2ip s Phone( I (,V ) 2 6 i - '7 Phone ( ) SPECIMEN INFORMATION {use reverse side for additional informations ANIMAL SPECIES: V, , s Breed %% Age _�� (Pet ❑ Stray ❑ Wild ❑ Unknown Why is animal to be tested? Human exposure ❑Pet exposure ❑Acting sick Symptoms: ❑ Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy,,, p Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other 6. Cause of death: ❑ Natural ,'(S(Killed Method Date of death z s e Vaccinated for rabies: ; Yes ❑ No ❑ Unknown Date of vaccination z�/ /c i Travel out of state: ❑ Yes K-No ❑ Unknown Where When Bitten by another animal within 12 months: ❑ Yes 12(Ro ❑ Unknown If yes, by what? oun In what TOWN was animal f? /U/r>v / - /< In what COUNTY? INFORMA.TION(use reverse side for additional information) PERSON(S) EXPOSED: Name_ Tf Street �/ %, : ..✓ , "% City/State/Zip Phone (su> ) .2 3 S'riz Type f ,Bitexposuree ❑: Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure 2 f v 2 Body site < 7,,,;, Severityof exposure Circumstance of exposure: ❑ Capture gHandling ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? Yes ❑ No ❑ Unknown Did'person receive rabies shots after incident? ❑ Yes g No ❑ Unknown Physician/Hospital Phone ANIMAL(S) EXPOSED: ► ITM Species Owner Street 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 Animal Rescue League Of Boston Veterinary Clinic 10 Chandler Street Client ID: 31221 Client Name: Valerie Kostaras Address: 17 Erick Rd Unit#21 MANSFIELD, MA 02048 Phone: (508)813-5863,ext. Tag Number: 1016 Lot Number: 1215200A/SQ Producer: Fort Dodge K / MLV: Killed Virus BOSTON, MA 02116 (617 )426-9170, ext.105 Rabies Certificate Patient ID: 31221-5 Patient Name: A110564 Species: FELINE Breed: SIAMESE/MIX Sex: Neutered Male Color: flame pt Markings: Birthday: 01 /01/2001 Weight: 7.30 pounds on 5/17/2002 Vaccination Date: Expiration Date: Staff Name: Dr. Amy Johnson, D.V.M. License Number: MA # 5250 5/17/2002 5/17/2003 REQUEST FOR RABIES EXANJIiNATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 FOR LAB:USE::ONLY Date. Received: - Lab Nb::, [ /A, ,�� SUBytITTER ��✓r✓ ,��' /t-Jy�s���Q Agency Owner or Person Who Found Animal 672 Street S ti yJ�sT s'T Street /I/ Lbdad/AAI City/StateOp City/State/Zip /,Itrld. Aft- 020V P_iy 2S- ?hone(_S�V) 26/'�- 730o Phone(pp) 37-P- 3223 SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: Breed cCoo.✓ Age Cl Pet ❑ Stray PWild ❑ Unknown 'Why is animal to be tested? Cl Human exposure 'X Pet exposure ❑ Acting sick Symptoms: ❑ Aggression ❑ Ataxia Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures C Unexplained wound OyFocnciclead ❑ Other Cause of death: ❑ Natural gKilled Method K 6 Date of death S' 9 0 Z Vaccinated for rabies: ❑ Yes ❑ No KUnknown Date of vaccination Travel out of state: ❑ Yes ❑ No ('Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No �f7nknown If yes, by what? In what I4'd�t was animal found? /LJ�S/ie%P in what COUN ? Z`//r EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street City/State/Zip Phone ( 1 Type of exposure: a Site C Scratch 0Other___ _ ❑ Lick ❑ Unknown Date of exposure Body site Severity of exposure Circumstance of exposure: ❑ Capture ❑ Handling 0 Specimen prep. ❑ Unprovoked attack ❑ Provoked attack Cl Indirect exposure ❑ Other Was person previously vaccinated? Yes ❑ No ❑ Unknown Did person receive rabies shots after incident? Yes ❑ No Cl Unknown PhysicianlHospital Phone ANIMALS) EXPOSED: Name 6 r�T / �r'i F"t, d Species 126-e--,a-*S Owner STirycr Co%({ alreet _ / znO vd r1,0,v /rv. City/State/Zip 1,iyA o70L_1j> Phone (SZP 37-P 3 2z3 Type of exposure: ❑ Site ❑ Scratch ❑ Lick 0 Unknown XOther /V P� w%� 106(rf Date of exposure � o Circumstances of exposure: ❑ Fight 'Vicinity ❑ Dead an contact ❑ Other Was animal's rabies vaccination up-to-date? ❑ Yes Xi o ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes )(No ❑ Unknown A LABORATORY RESULTS'- FLUORESCENT RABIES :ANTISOOY'TES.T Test Date a u POSITIVE(RASID) NEGATIVE: (NOT RABID), Q SPECIMEN UNSATISFACTORY ❑ E COMMENTS: � .pl- Core 01"014=� 05/1542002 WED 12:10 FAX 508 261 7425 TORN OF MANSFIELD [a 001 TX REPORT N::I: e: N: N: B::k N: N: N::1: 8: N: Y<:Y• e::V::k N::k N: TRANSMISSION OI{ TX/RX NO 0451 DEPT. ID 3652 CONNECTION TEL 95083391031 SUB -ADDRESS CONNECTION ID ST. TIME 05/15 12:09 USAGE T 01'21 PCs, 2 RESULT OK TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOAt2D OF HEALTH Date: - 1 5� c -- Time: f 6,Y a._.. From: Town of Mansfield Phone: 508-261-7366 Board of Health Fax: 508-261-7343 Six Park Row Mansfield, MA 0211048 TO: y Type of Form No of pages: Q '~ Message: (Incl. cover sheet) C�3 REQUEST FOR RABIES E.YATYM iATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983�385, -6387 FOR LAS USE:ONLY Dat& Re.ceivvea tC'q' (^�6- 66 Lab No::. d�Xlba t� t% SUBMITTER 0 ✓ �F /��%1Nl rf�� Agency Owner or Person Who Found Animal Street S o GrJcFs% ST, Street 80 0.4,4- .Si _ City/State/Zip CityfState2ip tiiu ri��/� �t� OcoY�'/r2r Phone (Sag ) 26 /- 7306 Phone (szr) 3-9— 2rzz SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: _<47— Breed Age ❑ Pet ❑ Stray - kff Wild ❑ Unknown Why is animal to be tested? ❑ Human exposure P Pet exposure ❑ Acting sick Symptoms: ❑ Aggression ❑ Ataxia A01sorientation ❑ Lethargy ❑ Paralysis. ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ' ❑ Other Causeofdeath: ❑Natural ($(Killed Method k/s m,Tr —1 Date of death s-,y oe Vaccinated for rabies: ❑ Yes ❑ No C(Unknown ' Oate of vaccinaUon Travel out of state: ❑ Yes ❑ No Plinknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No O Unknown If yes, by what? In what TDM was animal found? In what 2Q9NTY? /.s'iPvrT EXPOS'M INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street CityfStatel7jp Phone ( ) Type of exposure: ❑Site ❑Scratch ❑ Other ❑ Lick ❑ Unknown Date of exposure Body site Severity of exposure Circumstance of exposure: Q Capture ❑ Handling ' ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes ❑ No ❑ Unknown Did person receive rabies shots after incident? Cl Yes ❑ No ❑ Unknown Physician/Hospital Phone ANIMAL(S) EXPOSED: Name TAOlc�- Species Ae-1,�ec- G>Gh' Owner /,s o e, .CZV✓ x 6rreet f!o 06 A sY City/Slate p /Jn Phone(sdv) 339-2s12z Type of exposure: ❑ Site ❑ Scratch ❑ Lick Pq Unknown ❑ Other Date of exposure -rllr / z_ Circumstances of exposure: ❑ Fight ($(Vicinity ❑ Dead animal contact ❑ Other Was animal's rabies vaccination up-to-date? Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes ;KNo ❑ Unknown LABORATORY RESULTS - FLUORESCENT RASIES:ANTISODY'TEST Test Date L' 't� POSITIVE(RABID) ❑ NEGATIVE'(NOT RASID).t r( SPECIMEN UNSATfSFACTORY ❑ COMMENTS: �4 t\vj>)�m-0, witl �oAi est� 9<5 FOR' LAB:USE:.ONLY REQUEST FOR RABIES EXAi�IINATIOtY ,Date Received: 5a— 1 �.—tj� Stare Laboratory Institute, Virology Division i +, Rabies Laboratory (617) 983-6385, -6387 ab No::. `A My 2 2 0 02 SUBrMITTER �o��%w✓r���� Agency /,,. Owner or Person Who Found Animal ��✓/yam✓ Street S?J /.r/cs's% s;�_ Street__ City/State/Zip 021yd-122-r` City/State/Zip z!Lt ,64 / 'o e;,�,y� ipg� Phone JZY)_2G/-73oo Phone(pr) 339—V_7el SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: /fie T Breed Age ❑ Pet ❑ Stray Poild ❑ Unknown 'Why is animal to be tested? ❑ Human exposure KPet exposure ❑ Acting sick Symptoms: ❑ Aggression ❑ Ataxia ❑ Disorientation XLethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: )R�Natural ❑ Killed Method Date of death F71z / z Vaccinated for rabies: ❑ Yes ❑ No ,Zf Unknown Dale of vaccination Travel out of state: ❑ Yes ❑ No Al Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No `Unknown If yes, by what? _ In what TOWN was animal found? In what COUNTY? 151•r is / EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: ANIMAL(S) EXPOSED: Name Street City/State/Zlp Phone ( ) Type of exposure: ❑ Site ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure Body site Severity of exposure Circumstance of exposure: ❑ Capture ❑ Handling' ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? Cl Yes ❑ No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes ❑ No ❑ Unknown Physician/Hospital Phone Name � %/v Species 6 // F ids � Owner ir/�Nc �1 ✓ �(treet -- Z Z City/State/Zip oe�4,vs/s/<? min- 6zey.� .Phone (g'og) 339 Type of exposure: ❑ Site ❑ Scratch ❑ Lick XUnknown ❑ Other Date of exposure S 4 o z Circumstances of exposure: ❑ Fight Vicinity ❑ Dead animal contact ❑ Other Was animal's rabies vaccination up -to -dale? ayes ❑ No ❑ Unknown Did animal receive rabies booster after incident? Cl Yes X(No ❑ Unknown A LABORATORY RESULTS•- FLUORE.SCENTRABIESANTiBODYTEST Test Date S✓'/ 'OA a POSITNE:(RASID) t NEGATIVE: (NOT 'RABID).0 SPECIMEN UNSATISFACTORY ❑ E COMMENTS: V4, Ltof yvo r �d -Q, ttw v 4( ('.tuA ✓f) o �'wtf thi T�r✓1� p-0�lG� (h/9 f�`�� , '� 1.?Ol� GVIU�•a'u-2.t"inu� <Ywrr�/t4.� Y (/ Animal Rescue League Of Boston Veterinary Clinic 10 Chandler Street Client ID: 31221 Client Name: Valerie Kostaras Address: 17 Erick Rd Unit#21 MANSFIELD, MA 02048 Phone: (508)813-5863,ext. Tag Number: 1018 Lot Number: 1215200A/SQ Producer: Fort Dodge K / MLV: Killed Virus BOSTON, MA 02116 (617)426-9170, ext.105 Rabies Certificate Patient ID: 29524-1 Patient Name: 'Bailey" A086263 Species: FELINE Breed: DOMESTIC LONGHAIR Sex: Male Color: Flame Point Markings: Birthday: 03/30/2000 Weight: 16.60 pounds on 5/18/2002 Vaccination Date: Expiration Date: Staff Name: Dr. Bosmat Gal, D.V.M. License Number: 3834 5/18/2002 5/18/2003 JANESWIFr GOVERNOR ROBERT R. GITTENS ,SECRETORY , HOWARD K. KOH, MD, MPH COMMISSIONER The Commonwealth.of Massachusetts Executive Office of Health and Human Services Department of Public Health Statb,Laboratory'lnstitute ; 305 South'Street, Jamaica Plain, MA 02130 (617) 983-6200 ,) �'Ij MAY J 2 2QQ2 ii t Rabies, Laboratory, ext. 6385 05/20/2002 . Attn:'Mansfield Board of Health ILab•Number: RA02-0851 Animal: Bat ISubmitted_by: Mansfield Animal''`Control I ITe';t'Date: 05/11/2002 Result: POSITIVE'. Exposure information: Found in: Mansfield Mansfield 508-261-7300 . I-, ,IAniinal exposure Cat' Nancy Flynn (owner) Mansfield .' 508-339-4261 Comments: If you are'aware of any additional exposures, or have any corrections to this report, please call the above number., 1011 REQUEST FOR RABIES EM02LY NATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 FOR LAS USE::ONLY Datee Received: 70 d: 5-,cy�-6 Lab.No::. (ZA6;t— SLIBrti1ITTER �.,✓ rim,, Agency nZ Cs oi. v Owner or Person Who.Found Animal Dow AIAJ 1jy Street Street /7 51 s7 Cityl5tate(Zip City/State/Zip �A o2my� Phonerp) 2G/—mod 2306 Phone(jap) 335' 6k63 SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: F/. cf Breed os/y Age :-� ❑ Pet ❑ Stray Wild Cl Unknown Why is animal to be tested? 0:; iuman exposure Cl Pet exposure ❑Acting sick Symptoms: ,Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural ,`Killed Method Date of death Vaccinated for rabies: ❑ Yes ❑ No WTUnknown Date of vaccination Travel out of state: ❑ Yes ❑ No JAI Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No Rtnknown If yes, by what? In what TOWN was animal tg_u ? �/» ✓ram �� In what COUNTY? Z&1ra•7u j EXPOSUR.E INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name _ Di1a�✓ <Y,. Street —2! sT City/State/Zrp trip j f �� rGor U2a y� Phone Type of exposure: fi Bite O'Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure 3 22 oL Body site L,4,os v- Severity of exposure pk �eietiic Circumstance of exposure: ❑ Capture Handling ' ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes XNo ❑ Unknown Did person receive rabies shots after incident? ❑ Yes gNo ❑ Unknown Physician/Hospital Phone ANIMAL(S) EXPOSED: Name Species Owner �lreet . City/State/Zip Phone ( ) Type of exposure: ❑ Bite ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure Circumstances of exposure: ❑ Fight ❑ Vicinity ❑ Dead an contact ❑ Other Was animal's rabies vaccination up-to-date? ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes O No ❑ Unknown LABORATORY RESULTS' • FLUORESCENT RABIES?ANTIBODY 'TEST Test Date S✓a bI J U a POSITIVE: (RABID) ❑ NE'GATIVE(NOT RABIDA. K1 SPECIMEN UNSATISFACTORY ❑ COMMENTS: notl fl- 14 t1 C Q REQUEST FOR RABIES EYAilYMNATION Stare Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 SUBMITTER oF I/,�,, FOR LAS:USE::ONLY Date: Received:- Lab.No::. Agency Owner or Person Who Found Animal _ L�An v Y �i-4 V,, J Street S-0 C✓CsSr s Street I k/()O c/hST sT City/State/Zip Xi d 2cy P City/State/Zip Phone73oo Phone(,rg) 339 �977 SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: f24cceaaJ Breed Age 3-5'cvlrs ❑ Pet ❑ Stray 4 Wild ❑ Unknown 'Why is animal to be tested? ffuman exposure ❑ Pet exposure ❑ Acting sick Symptoms: ❑ Aggression []Ataxia ❑ Otsorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural ,Killed Method /ffZZ Date of death L /'i Q z Vaccinated for rabies: ❑ Yes ❑ No Unknown Date of vaccination Travel out of state: ❑ Yes ❑ No 9nknown Where When Bitten by another animal within 12 months: ❑ Yes CI No ,Unknown If yes, by what? In what TOWN was animal fsstad? ru in what �Q_ ? ltl T EXPOSM INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: a�'"'�/G�s✓;��Sh9 CuRgj Name �,r1 L�a/�,�?,✓, lG�muN.✓�rF2/r Street /yo— )t/y 9 City/State/Zp ",i- o 2eYb' Phone (oe) 33 9 — Type of exposure: ❑ Site ❑Scratch ❑ Lick ❑ Unknown A Other Dateofexposure 6�i� rGfi9 Body site lfig A&OS Severity of exposure A4,a ti n Circumstance of exposure: ❑ Capture XHandling ' ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes K`1 No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes R No ❑ Unknown Physician/Hospital Phone ANIMAL(S) EXPOSED: Name Species _ Owner ,reef City/State/Zip Phone ( ) Type of exposure: ❑ Bile ❑ 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 RABIES :ANTIBODY TEST Test Date L D,0— 6�d- POSITIVE: (RABID) ❑ NEGATIVE: (NOT 'RABID) '0..� SPECIMEN UNSATISFACTORY COMMENTS: elc� 4-Cd IVJ6 0� L A a u s e REQUEST FOR RABIES EXAMINATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6386, -6387 FD.R LAB USE ONLY... f ` ." bete Received; ::pCg: 'Zl � ' Lab No faA�2-(Zfo.. SUBMITTER G 1 tls c er Agency �, \ C^^ tirnU C� �c Owner r Person Who Found Animal Street 5p WeS� C ,�v �} q e 5SO City/State(Lp W e5� �, a f a M� � City/State2lp _ n1 \ A ��ny Phone (sus) s,9c� - as 15 Phone (sod) ?,39 - %ti a3 SPECIMEN INFORMATION (use revere aloe for additional Information) ANIMAL SPECIES: Fz lBreed L>�� Aga _lOa Pe( El 6tray ❑ Wild ❑Unknown Why Is animal to be tested? Human exposure 0 Pet exposure Acting sic Symptoms; O Aggression ,XAtaxia ❑ Disorientation XLethargy o paralysis Sal vatbn O seizures L7 Unexplained wound ❑ Found dead ❑ Other Cause of death; ❑Natural �Kllled Method_ Date of death f)) n a r I t Vaccinated for rabies: ❑ Yes XNo O Unknown Date of vaccination Travel out of state: ❑ Yes XNo ❑ Unknown Where 1" When Bitten by another animal within 12 months: ❑ Yes ❑ No Unknown If yes, by what? In what TOWN was animal "? sYIc—.�C \ —�_ In what COUNTY?— EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Ac •c 1 Street City/Slale(Zp rrlo- she\c9 MA ciao, b Phone (sro-o) _ -gy a3 Type of exposure: ❑ Bite ❑ Scratch ❑ Lick O Unknown Other Date of exposure b) 11 Body she- r,/ q Severity of exposure _ Circumstance of exposure: to ❑ Capture Handling ❑ Specimen prop. ❑ Unprovoked attack ❑ Provoked attack O Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes gNo ❑ Unknown Did person receive rabies shots after Incident? ❑ Yes ONo ❑ Unknown Physban/Hospital Phone ANIMAL(S) EXPOSED: Name Spades _ Owner Street City/Slale21p _ Phone ( ) Type of exposure: d Bile ❑ Scratch ❑ Lick O Unknown O Other Date of exposure Circumstances of exposure: ❑ Fight 0 Vldnity ❑ Dead animal canted ❑ Other Was animal's rabies vaccination up-lo-dale? ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes ❑ No ❑ Unknown LABORATORY RESULTS = FLUgRE3CENiHI IESANTIBODY TEST Tesumte (� POSITIVE (RABID).❑ NEGATIVE (NOT RABID)SPECIMEN UNSATISFACTORY El ' ( G �� 0 N L Y ZWN REQUEST FOR RABIES EXAtJINATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, •6387 FOR LA5.USEONLY Date: Received: d (n• - f - aL Lab No::. tZA'C-Z _ ( Z I Y SUBbIITTER Co �/� / Owner Person Who Found Animal Agency _�� or Street s 0 4624Y! -L�- Street 200 /fie/Co H s City/State/Zip 02c,yy City/State/Zip ivl 1<%P �� yc�iv-i�zs Phone(ag,) 26/ --7-406 Phone(��) 9'39•- 5'-7��r/ SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES:yPDsll w Breed Age ❑ Pet ❑ Strayild ❑ Unknown 'Why is animal to be tested? XPIuman exposure ❑ Pet exposure ❑ Acting sick Symptoms: ,,J ❑ Aggression ❑ Ataxia jl Olsodentatlon ' ethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ dther Cause of death: ❑ Natural KKilled Method die) /' Date of death G ze Vaccinated for rabies: ❑ Yes ❑ No gUnknown Date of vaccination Travel out of state: ❑ Yes ❑ No ZUnknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No nknown If yes, by what? In what TOWN was animal found? In what COUNTY? EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name �/io-✓J�i� A.), �Co a^ Street ZGE City/State/Zip o2a v.Y Phone(gy) .-'2,1Pq Type of exposure: ❑ Bite Cl Scratch ❑Lick kUnknown ❑ Other Date of exposure Body site v,-s -oc[F Seventy of exposure r C�i✓oH ✓ �.-� Circumstance or exposure: ❑ Capture ,Handling ' ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes /�ZNo ❑ Unknown Did person receive rabies shots after incident? ❑ Yes R No ❑ Unknown Physician/Hospital Phone- ANIMAL(S) EXPOSED: Name Species _ Owner Street City/State/Zip Phone ( ) Type of exposure: ❑ Site ❑ 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 u LABORATORY RESULTS`- FLUORESCENT RABIES?ANTI800Y TEST Test Date A a POS nVE:(RASID) ❑ NEGATIVE (NOT RABID) �j'�'f SPECIMEN UNSATISFACTORY El u TY E COMMENTS: C)l A 09 Y REQUEST FOR RABIES EYA aNATION FOR CAB::USE::OtJLY State Laboratory Insdrute, Virology Division Date. Received:" _( •�. j -Q� Rabies Laboratory (617) 983-6385, -6387 Lab No::. (( z - ( 2 S S SUBIIITTER e,--d�%m✓�L�/� Agency ra.✓ina/ Owner or Person Who. Found Animal ';q "c Street a r.✓c-S% _5;�_ Street_ City/Slateop Clty(State0p Phoney) 29/-7B0u Phone&7p?) 339^ SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: aC JCCoo.✓ Breed Age /T i ❑ Pet ❑ Stray • Wild ❑ Unknown 'Why is animal to be tested? ❑ Human exposure jXPet exposure ❑ Achng sick Symptoms: ❑ Aggression ❑ Ataxia rlsodentation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural 4 Killed Method S�v7— Date of death::: Vaccinated for rabies: ❑ Yes ❑ No ,SiUnknown Dale of vaccination Travel out of state: ❑ Yes ❑ No X Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No )kMnknown If yes, by what? In what DONN was animal Land? A zem.iI /,,r// Ih what COUNTY? EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street City/State/Zip Phone ( ) Type of exposure: ❑ Bile ❑ Scratch ❑ Lick ❑ Other Date of exposure Body site Severity of exposure Circumstance of exposure: ❑ Capture ❑ Handling ❑ Specimen prep, ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes ❑ No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes ❑ No ❑ Unknown Physician/Hospital Phone ❑ Unknown ANIMAL(S) EXPOSED: Name /�'G�i✓0 Species C� ✓< ✓� Owner If( reet z 2r- Carder si, City/State/Zip /4-/0 0261N.r=132s"' Phone(Sa8) 5?3s-- Gisv Type of exposure: ❑ Bite ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure A v /e- Circumstances of exposure: tKFight Cl Vicinity ❑ Dead an contact ❑ Other Was animal's rabies vaccination up-to-date? g Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes qNo Cl Unknown u LABORATORY RESULTS' • FLUORESCENT RABIES ANTIBODY TEST Test Date COd 1A d A - a u POSITIVE:(RABID) NEGATIVE (NOT RABID), SPECIMEN UNSATISFACTORY ❑ s COMMENTS: } ( I �{fntSFicLc( �QYI a OJ91 Wt I nbtlf OLk~ _. 06-Z, 61- .14 n (IV 0 CA LL. Y JANE SWIFT GOVERNOR ROBERT P, GITTENS ,SECRETARY HOWARD K. KOH, MD, MPH I COMMISSIONER The Commonwealth of Massachusetts Executive -Office of Health and Human Services Department of Public Health State,Laboratory Institute 305 South, Street, . Jamaica Plain, MA 02130 (617) 983-6200 Rabies Laboratory, ext. 6385 08/ 26/2002 Attn': Mansfield Board of riealth (Lab Number: RA02-1255 Animal: Raccoon ISiibmitted.-by: Mansfield Auimal,Contr61.. I ITest'Date,: 06/25/2002 Result:, POSITIVE Exposure information: j 'Altv j 7 002 Found in: Mansfield Mans,f ie,ld 508-261-73001, (Animal exposure'. I I Dog' Ruth.,Burgess (owner) Mansfield 508-339-6194 Afi Zr -el�eVer ,QUEST FOR RABIES EXAMiNATI©N��� State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6386, -6387 SUBMITTER ANCiEt t `sAt=MOMi � P Agency 35m Sn E ld a s�,noQT nerarPat Street $C3CTd� a " Street_ City/State/Zip SQ d6G�i i\iLR9� ea �t ire' s City/State/Zip Phone( ) FOR AP PTS. flf�i� s r--� S. Phone (5pq FOR LAB USE ONLY Date Received: Lab No:. UOZ -6 N r3 Who Found JrEl IMLIN uvr'URMATION (use reverse side for additional information)N�'m ANIMAL SPECIES: 1, 0 Breed -� S-W Age � pet ❑ Stray ❑ Wild ❑ Unknown Why is,animai to be tested.?,l(Human exposure ❑ Pet exposure AActing silt Symptoms: ❑ Aggression XAtaxia ❑ Disorientation Miethargy &Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑ Natural niLlOted _ Method e uU., a A a s ne- Date of death 1 / r 'I /O Vaccinated for rabies: Piles ❑ No Cl Unknown Date of varxinaGon 52'Rg�o� Travel out of state: ❑ Yes l�Io ❑ Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No AMnknown If yes, by what? Ptd# In what IM was animal foyp. ? j t44 In what CDUy_'C(7 EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: ANIMAL(S) EXPOSED: Name vcttavt ri0 ,fie. L_�rr ; Street Y City/State/Zp c Phone (G17) 5-220-_ aLlfi-- Type of exposure:' 4wC � v- P11pite ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure 7 T-/6T Body site tg w Severity of expodtt6t ? Circumstance of exposure: ❑ Capture /VHandling ❑ Specimen prep, Cl Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes i&No ❑ Unknown Did person receive rabies shots after incident7..UW211 ❑ Yes ❑ No ❑ Unknown (,clew �1SPaA Physidan/Hospitai Phone Name Species _ Owner _ Street City/State/Zip Phone ( ) Type of expos (e: ❑ Bite `. ❑ Scratch 0 Lick ❑ Unknown ❑ Oth r Date of exposure ' Circumstances of exposure: Cl-Fidht ❑ 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\ ' REQUEST FOR RABIES EXAM[NATION FOR LAB USE GNLY � State_ Laboratory Institute, Virology Division Date Received Rabies Laboratory; (617) 522-3700, x194/196 Leh No, ry SUBMITTER k-AAAJGY.L Agency Lo Vo ve , cZW—� Owner or Person Who Found Animal Stw:, t,seMs Street 944- A MAi j Street (11 Eh,65 A,/,e— City/State/zip WAS-LL,E rtin cY2F t City/State/Zip _ 94�ns&U V0, 02-o413 Phone (h)S ) obo- 9Sib i Phone ( S�e) 539 - Zt9 t SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: i OA6iS i, Breed ' Age u ❑ Pet Stray ❑ Wild ❑ Unknown Why is animal to be tested? 0Human exposure ❑ Pet exposure Acting sick Symptoms: ❑ Aggression Ataxia ❑ Disorientation Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑Unexplained wound ❑ Found dead 00ther. 2*\ore%t2s4 t�za 1 t{ u,Qau ess r �L Cause of death: ❑ Natural Killed Method Routl,z-�s�a Date of death > {/2-to2 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 fo MR4srtei-i''3 In what COUNTY? _U-475- b EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Siiea-i ese,4s-TAp—, + D r�r19tY Street u t F2Auo s Avg City/State/Zip r^aNsr Eti n t 02048 Phone (,roe 339- Zt9 t Type of exposure: ❑ Bile ❑ Scratch Wt ick ❑ Unknown ❑ Other Date of exposure _n,iol- lzsf weCln. Body site ha is Severity of exposure 4 w n Circumstance of exposure: ❑ Capture AHandling ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes' `CANo ❑ Unknown Did person receive rabies shots after incident? ❑ Yes . Po ❑ Unknown Physician/Hospital Phone ANIMALS) 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 REQUEST FOR RABIES EYANILNATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 SUBMITTER FOR LA&USE::ONLY Date; Received: ! 0 ' <c7' OZ Lab -No:: 0 Agency %,; ✓ o� >�i. rc L r<� <r,, Owner or Person Who Found Animal �Y.✓ o t ✓ Street S�) NJvsi ri• Street _Zr) City/State2ip City/State/Zip Phone (_�oy) 2Gi- ✓Sop Phone(yoji 33ti— do;3'7 SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: a r Breed Age /0t-44'1 ❑ Pet ❑ Stray ❑ Wild )ZItnknown Why is animal to be tested? �*uman exposure Cl Pet exposure ❑ Acting sick Symptoms: OAggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound Cl Found dead ❑ Other Cause of death: ❑ Natural f Killed Method Date of death Vaccinated for rabies: ❑ Yes ❑ No p�Unknown Date of vaccination Travel out of state: Q Yes ❑ No X Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No (Unknown If yes, by what? In what I was animal (Quad? /%/< /P In what COUM %1rr.lT/ EXPOSURE MOFLN ATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street 3c U Ccrn�i r/ Si CitylState/Zp Phone (�dg) Type of exposure: ❑ Site JQ Scratch 0 Lick 0 Unknown ❑ Other Date of exposure to 1 o e Body site o Severity of exposure ScirT%d - Jiiaz✓ Circumstance of exposure: ❑ Capture IZ Handling ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes ONo 0 Unknown Did person receive rabies shots after incident? ❑ Yes WNo ❑ Unknown Physician/Hospital Phone ANIMAL(S) EXPOSED: Name Species _ Owner Street City/State/Zip Phone ( ) Type of exposure: ❑ Site C3 Scratch ❑ Lick ❑ Unknown �N11�4 Date of exposure Circumstances of exposure: ❑ Fight ❑ Vicinity ❑ Dead animal contact O Other Was animal's rabies vaccination up-to-date? ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes CI No ❑ Unknown LABORATORY RESULTS- FLUORESCENT. RABIE.S:ANTIBODY'TES.T Test Date tD Game? POSITIVE: (RABID) ❑ NEGATIVE (NOT'RABID) �fSPECIMEN UNSATCSFACTORY ❑ COMMENTS: /Vf3et{ REQUEST FOR RABIES E<YAAMNATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 FOR LAB'::USE'.ONLY DaterRe.ceived: ! L9 Lab No:: .244D7-= Zb S S SUB1tITTER ��c�•J. /y%siifi� Agency ✓ / C o J / o / Owner or Person Who Found Animal. 14,✓ Street SJ Inl rs% s7- Street City/Slate/Zip i City/StatetZip ?hone .� 26 / — 73oU (goy) Phone (5'd8) SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: rod Breed Age ❑ Pet ❑ Stray }Wild ❑ Unknown 'Why is animal to be tested? ❑ Human exposure OI Pet exposure ❑ Acting sick Symptoms: ❑ Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑Natural RKilled { Method S� e i Date of death /o iyl z Vaccinated for rabies: ❑ Yes ❑ No iN Unknown Date of vaccination . Travel out of state: ❑ Yes ❑ No 09"Unknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No Unknown If yes, b what? In what TOWN was animal fpstn. ? ��/� /ir/( In what COUNTY?,�l o EXPOStRE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street City/State/Zp Phone ( ) Type of exposure: Cl Bite ❑Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure 9ody site Severity of exposure Circumstance of exposure: ❑ Capture ❑ Handling ' ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes ❑ No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes ❑ No ❑ Unknown Physician/Hospital _ Phone ANIMAL(S) EXPOSED: Name CAI Species Owner 14 o sly ti ✓ Streetyo G✓o/ nisi City/StatelZip Phone (roy) 739-7ryi Type of exposure: ❑ Bite ❑ Scratch ❑ Lick Unknown ❑ Other Date of exposure /o l 2 Circumstances of exposure: ❑ Fight Vicinity ❑ Dead an contact ❑ Other Was animal's rabies vaccination up-to-date? Kyes ❑ No ❑ Unknown Did animal receive.rabies booster after incident? ❑ Yes ❑ No gUnknown u A LABORATORY RESULTS'- FLUORESCENT RABIESANT1800Y TEST Test Date , 8 Pb— u POSITIVE:(RA81D) 0 NEGATIVE.(NOT RABID) //K SPECIMEN UNSATISFACTORY ❑ s COMMENTS: 1 r b l� Y 0 g 1 D--6- 4-6 F,IL REQUEST FOR RABIES EXAILYM iATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983.6385, -6387 FOR LAB USE*ONLY Date: Received 1 U—a,9-OA Lab..No::. SOa-a75 j SUBNIMER `g df Agency d221 , C ,,77 o Owner or Person Who Found Animal G/t«d_ Street L✓cSt % -s f Street 3/ Sri /7;� s% City/S I a te/Zip it ,g svd'-i.321- City/StatelZip 1ln o2<vyy-IS21- Phone7o/- 73 oO Phone(Gg) 53 9 - Yo >'�7 SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: bAorsaiy Breed Age ❑ Pet ❑ Stray gWild ❑ Unknown 'Why is animal to be tested? Human exposure gPel exposure ❑ Acting sick Symptoms: ❑ Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound Wound dead ❑ Other Cause of death: o Natural ❑ Killed Method Date of death /o zz oz Vaccinated for rabies: ❑ Yes ❑ No CJ(Onknown Date of vaccination Travel out of state: ❑ Yes ❑ No JZUnknown Where When Bitten by another animal within 12 months: ❑ Yes ❑ No /M Unknown If yes, by what? In what I was animal fcund? JnNsF,//WP In what GQUNIY? 64,s, � 1 EXPOS�i INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street City/State/Zlp Phone ( ) Type of exposure: ❑ Bile ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Date of exposure Body site Severity of exposure Circumstance of exposure: ❑ Capture ❑ Handling ❑ Specimen prep. ❑ Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes ❑ No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes ❑ No ❑ Unknown Physician/Hospital Phone AMNLA, (S) EXPOSED: Name f1s/�crY �/is� Species �9 vi ✓Lr Owner /3o,94y F: s4G12u6r street 31 s M,iZ sT City/State/Zip / .3N1/ice/<P A-,1.4 0Z4'ye-122 Phone ( fuff) 33 S - /0 5� Type of exposure: ❑ Bite ❑ Scratch ❑ Lick f$ Unknown ❑ Other Date of exposure /a z, a ? Circumstances of exposure: ❑ Fight ❑ Vicinity Dead animal contact ❑ Other Was animal's rabies vaccination up-to-date? jb(Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes ANo ❑ Unknown LABORATORY RESULTS - FLUORESCENT RABIES:ANTiBODY TEST Test Date 16 -2-1 _ GL POSITIVE: (RABID) ❑ NE'G'ATIVE(NOT RABID) v�kr� SPECIMEN UNSATISFACTORY ❑ COMMENTS: p f ANIMAL(S) EXPOSED: Name M0t1& Species Owner Street awstate0p Phone( ) Type of exposure: ❑ Bite 0 Scratch ❑ Lick ❑ Unknown 13 other Date of exposure Circumstances of exposure: ❑ Fight d Vicinity ❑ Dead anima! contact ❑ Other Was animal's rabies vaccination up-to-date? ❑ Yes ❑ No O Unknown Did animal receive rabies booster after incident? ❑ Yes ❑ No 0 Unknown -- 7� s d ie w1 ) a , Val-, —J�2,t �� s� /t/%Z :REQUEST ST FOR jgAVIIEES F+MANjU1 ArjoS i ( FOR LAB USE ONLY State Iatm ,cay Institute, Virology Division UG-ste Received.(}p poi %bitI.a s L;::.tory (617) 3E3-6385, -b3d6,=o3i?'7 l a;_, No:. �A') � 1 A t%w � �' 1st ,er or f:,.nwn'Nim Found Animal S6sat-FQSIOV _ f✓tff IV C!ty Sta#erKr fr Ciiy1S#ate E MN tV FPhone�— R APPT� A ��s�1� Phrefs�- �L V� 1D Jg _ Sr'Es".:0✓IEPd 'A NT0RMfet,TI0FT (use raMu side for arldiyanal ANIMALS G1ES.L N Bte �% S C t Ago_ �ii2 , et EI SIIRv L 4i;ry s aniraral to kte tested? CJ tiuman�asur-^ C7 Pat acute oJn� s;e;ciG Un„nurrn Symptoms is Aggr -ision tv,:12 i�lW!/mWa6on tic py r'aralys' 0 SaJvation fJ 5u at5s C7 UnGVlained wound 17IF !, nd dezd ttrar )' rJ V Gih ht anZ. c �oUs �q C� hor�f FFS i7N C5 � Cause of deattr. ❑ Ai=aturaly ii!ed _ Method d' girt c�- b 0 r b iF�r(xjjate of death 7•-Gz "ham fy,5 V-,CC4naIA,d tie rahles: �� /=s o No p Unf ncb=ri; Dniv of vaccination j 0 7 — z a Travel out of state: GVYes ❑ No ❑ Unknown ��t:ere C ri / i cr rn i 9 When L ii jrc e/ �G ire tty {r/ (JO fch Sitten by another animal ;i!thin 12 months: d Yes tMo 0 Unknown if yes, by what? �onL In what im was animal found? A III q 1-.7p-L19 In u,r„: rnr,arrvo 0 <_._ r . E"�POSIM INFORMATION (use reverse side for additional information) PERS0I"N(S) E OSED: Name 5 S 0 0 Street 3 O SSf Ilit ) I ck AI/e CiWState0p i3 a S f O vJ , 1 4- G2 7�0 Phone (617) S `f (- d 3 `f Type of exposure: 0 site ❑ Scratch ❑ Unknown ❑ Other Date of exposure 2- 16 L Body site La vt S Severity of exposure r Circumstance of expose' ❑ Capture IL ❑ Specimen prep. p Unprovoked attack ❑ Provoked attack . ❑ Indirect exposure ❑ Other Wa , pepon previously vaccinated? 0/yes 0 No ❑ Unknown Did person receive r��hies shots after incident? ❑ Yes C�7'No ❑ Unknown Physician/Hospital Phone