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HomeMy WebLinkAboutRabies - 2004REQUEST FOR RABIES EYANMNATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6387 FOR tA&USE.ONLY Date: Received: Lab No:: �A 024 SUBMITTER 0 Agency Owner or Pe son Who Found Animal Streeto L1JI S i sT•• Street.- City/Slate2ip City/Stateop i✓F /� , �,� <,z o Y /� Phone 7ai) Phone SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: 8reed / rh Age i i / ` ❑ Pet q'Stray O/Wild ❑ Unknown Why is animal to be tested? Cikuman exposure ❑ Petexposure ❑'—Actcting sick Symptoms: . /5Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis ❑ Salivation ❑ Seizures ❑ Unexplained wound ❑ Found dead ❑ Other Cause of death: ❑Natural /4 Killed Method lL/%,1/ ,-,,7, Date of death z Id� Vaccinated for rabies: ❑ Yes ❑ No Z Unknown Date of vaccination . Travel out of state: 0-Yes ❑ No ,9 Unknown Where When Bitten by another animal within 12 months: Cl Yes ❑ No Q'Unknown If yes, by what? In what TOWN was animal found? In what v COUNTY. TION (use reverse side for additional information) PERSONS) EXPOSED: Name i�/!a� //m>u - lac ✓ ✓ts Street City/Slate/Zup /v/> ✓S/ /�W ivies ozaie Phone 7L?2 Type of exposure: ,Bile ❑Scratch ❑Lick ❑Unknown ❑ Other Date of exposure Z 6 /a Body site Severity of exposure 6% n Circumstance of exposure: ❑ Capture (Handling' ❑ Specimen prep. C3 Unprovoked attack ❑ Provoked attack ❑ Indirect exposure ❑ Other Was person previously vaccinated? ❑ Yes Z No ❑ Unknown Did person receive rabies shots after incident? ❑ Yes ❑ No ,®.Unknown Physician/Hospital Phone AMMAL(S) EXPOSED: Name Species Owner gfreel City/Slate/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 -dale? ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes ❑ No ❑ Unknown LABORATORY RESULTS • FLUORESCENT RABIE.S'ANTIBODY'TEST Test Date C;t-/` POSITIVE: (RABID) 0" NEGATIVE: (NOT 'RABID)'X,�'( SPECIMEN UNSATISFACTORY ❑ E CGIvIMtN 1 S: G7k euvY Y 09/12/2004i09:47 FAX 617 989 0819 MRR-12-2004 09105 13PHC CDC PROGRAM REQUEST FOR kaIES EXAMINATION State Laboratory Institute, Virology Division Rabies Labisratoty (617) 983-6385, -6387. SYMMITTE R Agency Aj!..qj Street --A-T° Phone ( @1002/002 617 534 5905 P.0J3 Form Completed owner or Person WB h uwld Amm l t �✓ '- � fi� . r Vry Street /So. ' 11 City!$IA zip nJ/•r 03 rr5' Phone SPECIME I'-(1QdFORMATION {use reverse side for additional informalion) ANIMAL „PECIES: ,; p lip a Bread SH Age Ahqu , et ❑ Stray O Wild ❑ Why is animal t0 be tested? krHuMan exposure G; �t exposure ❑� Adilig lck Symptoms: / 1:1 Ajgrewldn © Ata4a [I Disorientation ElLethargy ID Paralysis ❑ 331!VatlOh Seizure's 0 Unexplained ound O Found dead Q Other —, '.- ' ti'de5eiar9eaui: =•na[ur�l—iJIHIIe�—=-�.:.Brnpt�;_.. . _ i ..wvc .., r+caul��,Av$` f,�• -; •----...'.,"�-: Vaceina,tedltor ' les�pa(es-•-o,Na �{f•Unknvv>a—..Date oiyaCClp�,ton' �„-• - I ., Travel ciut of state: Yes ❑ No ❑ unknown Where i`1 _ When T.__._-... Bitten b/ another a pirmal within 12 months; ❑ Yes '0 NO, XUnkriovm If yas, by what? animalLu? C�nM-cKSmJC4Z/ 1inwhat vas, EXPOSURE XNIPORMATION(use reverse side for additional information) I. PERSON S) L... " D: ANiMAL(S) E2WOSEIDI Name;, '�fn� r2i:i Name M':T—t f �NI Stree%`'Sis ..r�,:' ;',:c;:••..i, .3 Species City/S ataip 'r�' �;:z,'(I s: Owner nhane(5':Aj .'f3°l= �;'�t i i ,.. .., .__. Street --- --••-- Type of exposure: City/State2p Vrshu.° 0 SMich ❑ tick ❑ Unknown Phone ( j C outer Type ofexposure: Date of exposure _ 5TL14 17 site - 13 scratch Glick ❑ Unkrio n Bodysite,6LL.+i jgil,;-b, nnv{dl, Al 4,.y3 13 Other SeverityoP exposure rr-ertiexzAc Date of exposure Ciroumstance of exposure: Circumstances of expusurei I ! 0 CalAure 'gr•Handlinq ❑ Specimen prep. ❑ Fight ❑ Vicinity O Dead animal contai t ❑ Unprovoked attack 13 Provoked attack ❑ Other ❑ Indirect expoAire I3 Other Was enlmars iabies vacciheilon'up fo date? Was perarri previously vappnated? 7R?ees O No 13 Unknown ❑ Yet; 'Vo ❑ Unknown Did animal rgcelve rabies booster after incident? Did person' receive ratifies shots after incident? G Yes []No 13 Unknown ❑ Yeas ZVo I C3 Unknown Physiciand•iospitalta Csti rta! 1��.Lt u Phone'�3t'32"�'r _ r a, IS1`,PL19ntflTrt2%kF1fESktyTte.,gD;tS'TST::. 7esftGlate--- E 1 •b.. � � C. p.. •f Y .�.tr.�l: \pCi�'�v••h'� .f', Y�1, $Y •�r�'!i,�{�',ii i�r.i �� '•'',f 1 ,,Y:-, "ICY., li"'", � -+t.': .'� �dl /My 9Nj.r '�..a �� CS ,A.(•l[ 1.%�f f h •.''.. v''' �''�.?'.`�?C£��,.1 !i ,� Qi • ..iy; ABt�' �t// �:•:S • ' �(ii�E�1,N. A'I.aSFA>fl., ' it µ 1�•t�Y'� a �•, I r'��'' �'�� �45;: u y . -� _: , i ��.�;��.'• I , ,":is �t., K•:T.v:A .{ `,1 NO'Ft ,•+• V I • . MAR 1� TOTAL P.03 03/12/2004 09:47 FAX 617 983 6813 fal001/002 TO: USETTS DEPARTMENT OF PUBLIC HEALTH STATE LABORATORY INSTITUTE 305 SOUTH STREET JAMAICA, PLAIN, MA 02130 SURVEILLANCE PROGRAM TELEPHONE (617) 983-6801 FAX (617) 983-6813 i CONFIDENTIAL TO ADDRESSEE ONLY P SUT;J1CT: `flkal 014(z Woo,-" " FROM.- DATI : it;21�CS Y II NUMfC m OF PAGES TRANSMITTED (INCLUDING"THIS COVER SHEET): �.S SENT TO FAX NUMBER: CONTACT PERSON: a82( I- 10&5 i TELEPHONE NVIMMER: *CONFIDENTIALITY NOTICE* The pages compri4ing this fax transmission contain confidential information from the Bureau of communicable Disease Control. This information is intended solely for use by the individual named as recipient hereof. If you are not the intended recipient or such recipients employee or agent, be aware that any disu:losure, copying distribution or use of the contents of this fax is prohibited. If you have received this fax in rrror, please notify us by telephone immediately so that we may arrange to retrieve the fax at no cost t you. Note; • II IF APIY PROD EM OCCURS WITH TRANSMISSION, PLEASE CONTACT PALMA AT (617) 983-6801, TIiANK YOU, I REQUEST FOR RABIES EXAMINATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385,-6387 F`p FOR'LAB USA ONLY � �k` 1 , 5. Date Repeive, a - RtY04-0556 Lab No: Rec'd:_�t_/ 6 liavVII& SUBMITTER j�2 �tG(Qlti t�4iC-Lr�Yzc?v.sY--� Agency Owner or Person Who, Found Animal Toll,, Waak'n Street qq. (oreswel( �S-' Street 71 �)arscvnaSf City/State/Zip Mapsk-(se-lef M� C�Ztijti _ City/State/Zip �21U r' /c� l�ae4- oeNJa Phone(ivl?) Phone(-?o ) t;3ri- �/33) SPECIMEN INFORMATION{use reverse side for additional information) ANIMAL SPECIES: Ca IMelid Breed _-((aL 6Y� Age , i% CN'Pet ElStray ❑ Wild ❑ Unknown Why is animal to be tested? ❑ Human exposure 0 Pet exposure ❑ Acting sick Symptoms: � El Aggression El Ataxia ❑ Disorientation El Lethargy El Paralysis El Salivation UYSeizures ❑ Unexplained wound t4'Found dead ❑ Other o r wt I bud ram( ox U, Cause of death: f9 J�atural ❑ Killed Method Date of death Vaccinated for rabies: ❑ Yes DI -No` ❑ Unknown Date of vaccination Travel out of state: ❑ Yes t-No ❑ Unknown Where When Bitten by another animal within 12 months: ❑ Yes (❑ No)✓ nknoCJ wn If yes, by what? _ In what TOWN was animal found? I'Y16r^9,e ld In what COUNTY? _[� EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Vt(rV_0__ Street City/State/Zip Phone ( ) Type of exposure: ❑. Bite ❑ Scratch ❑ Lick ❑ Unknown ❑ Other__ Date of exposure Body site Severity of exposure Circumstance of exposure: ❑ Capture El Handling ❑ Unprovoked attack I ❑ Specimen prep. u Inairectexposure _ _❑ Other Was person previously vaccinated? ❑ Yes ❑ No ❑ Unknown Did person receive rabies shots after incident? i7 Yes ❑ No ❑ Unknown Physician/Hospital Phone ANIMAL(S) EXPOSED: Name oaclo(oc(L v m(2s wed Species Owner Street City/State/Zip Phone ( ) Type of exposure: ❑ Bite ❑ Scratch ❑ Other Date of exposure Circumstances of exposure: ❑ Fight ❑ Vicinity ❑ Lick ❑ Unknown ❑ Dead animal contact Was animal's rabies vaccination -up-to-date?— ❑ Yes ❑ No ❑ Unknown Did animal receive rabies booster after incident? O Yes ❑ No ❑ Unknown t LABORATORY RESULTS FLUORESCENT RABIES ANTIBODY TEST Test Date A_ o POSITIVE (RojpD ❑ NEGATIVE.(NOT RABID) wry' SPECIMEN UNSATISFACTORY ❑ COMMENTS: (• e t, 00 F1 N Q F1 Q O 'a C y ¢ t❑Q N UJ o0 FY Y Q F1 Q O 'gyp Q y 0 CJ V1 00 I� y Q 4d Q O tJ � 0 y dl V1 00 /b� y Q Ei Q O u Q it id L V1 X k bp ro � T � tXG 'O N �p N TJ 4l PO Cl y y O y y O y y O d y O a a u a a y a a u a a u " b G O. u u a v G aki O. � o0 00 V d a 0 0 0 0 L' � ❑O T N O y Vl Q � � O W N O y`�i 01 O O� M c .r r ti r �I M REQUEST FOR RABIES EYAIIVEWATION FOR LAS USE: Or State Laboratory Institute, virology Division Date Receives rb\Radd AK Rabies Laboratory (6l7) 983 6385, -6387 lt Lab No::. 1-w Agency OwnerorPerson Who Found Animal 6y Street f� [Nc=s S% Street —795- /' City/SlatelZip i Z�, r;< / r. /v/y u i� Ci /State/Zi Phone( oy)_ 2G/- 73oL ty P-� ��,.. S Phone (gay) z[. Z._ of SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES: =Al. -k. (X°2Breed Age?0 Pet ❑ Stray ^Wild ❑ Unknown Why is animal to be tested? ❑ Human exposure Pet exposure ❑ Acting sick Symptoms:. ❑ Aggression ❑ Ataxia ❑ Disorientation ❑ Lethargy ❑ Paralysis XSalivaton ❑ Seizures ❑ Unexplained wound ❑ Found dead )aOther //, ti Cause of death: ❑ Natural g'Killed Method ,lt oT Oatero death �/z Vaccinated for rabies: ❑ Yes ❑ No 0 Unknown Date of vaccination 716 Travel out of state: ❑'Yes ❑ No /O'Unknown Where When 'Bltten by another animal within 12 months: ❑ Yes ❑ No R Unknown If yes, by what? In what LQL was animal found? In what COUNTY? ldyLf j INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street City/State/Zp Phone ( ) Type of exposure: ❑ Bite ❑ Scratch ❑ Lick ❑ Unknown ❑ Other Dale 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 Phy&ian/Hospital Phone ANIMAL(S) EXPOSED: Name /r.Qi1�' EX n/ Species 4/Gs / z Owner /�eaex,( Street :> > f le City/Slate/Zip 2�,..r r/✓/�t /v v 2 y .Phone Type of exposure: ❑ Bite ❑ Scratch , ❑ Lick ❑ Unknown I<TOther 01 cX i.>%Ts Date of exposure ° 'Z/27/c ti 17 Circumstances of exposure: ❑ Fight gVicinity ❑ Dead animal contact ❑ Other Was animal's rabies vaccination up -to -dale? VYes ❑ No ❑ Unknown Did animal receive rabies booster after incident? ❑ Yes 0No ❑ Unknown LABORATORY RESULTS'-• FLUORESCENT RABIE.SA,NTIBODY'TEST Test Date POSITNE:(RASID) [ NEGATIVE -;(NOT RABID) .taS�� SPECCIMEN UNSATISFACTORY ❑ COMMENTS: pVj r��s ; J( /-VL 6 lIQ( .)pecfinen mequesi corm Tor K-Mes...iesting D gpu4u} STATE LABORATORY INSTITUTE Ree& /i 305 South Street k�,(��E�S Jamaica Plain, MA 02130-3597 - ' '.EASE PRINT Tel. 617-983-6385 DO NOT ABBREVIATE Date Received . PROVIDER/SUBMITTER INFORMATION 2. OWNER INFORMATION (or person who found animal) Name Name: Last First Initial - Address: No.%Street/Apt.# -- Address: No./StreeUApt # --- "--- Ciq/iown State Zip Code City/Tov✓n State Zip Code Phone Number: 3. SPECIMEN INFORMATION* ❑ Pet ❑ Stray ❑ Wild ❑ Unknown L"autsh eof ❑ NaVral ❑ Euthanized I Species _ creed p,9_ D,,.,'tiC_2_ Method Location Where Animal Symptoms: ❑ Found Dead ❑ Seizures Reason for Rabies Testing: was Found. ❑ Aggression ❑ Lethargy ❑ Unexplained ❑ Human Exposure Town ❑ Ataxia ❑ ParalysisWound ❑ Pet Exposure ❑ Disorientation ❑. Salivation ❑ Other ❑ Acting Sick _County __ Travel Out of State Bitten by Another Animal in Past 12 Vaccination History: date ❑ Yes Months: ❑ Rabies Vaccinated (Location Date_/_! ) ❑ Yes (type of an ) ❑ Not Rabies Vaccinated not current ❑ No ( ) ❑ No ❑ Unknown ❑ Unknown ❑ Unknown 4. EXPOSURE INFORMATION 'sons Exposed Exposure Date, Animals Exposed Exposure Date__ — Name Physician Name Name — Address: No./Street/Apt.# —" Species Age— City/Town State - Zip Codef___X�ddressStreet/Apt.# (ifdifferentfrom owner)own Number: ( ) Number: Stale Zip Code BiteoSite❑ _❑ Bite BodySite Type of Exposure: ❑ Scratch ❑ Lick ❑ Scratch Exposure:❑ (check one) Other Lick❑ k one) ❑ Other ____of 3euerity Severity ❑ Unknown ❑ Unknown ❑ Capture ❑ Specimen Q Fight - Circumstance ❑ Unprovoked Attack Preparation Circumstance ❑ Vicinity of Exposure: ❑ Provoked Attack ❑ Other of Exposure: ❑ Dead Animal Contact (check one) ❑ Handling (check one) ❑ Other Pre -Exposure Vaccination History: Post -Exposure Rabies Pre -Exposure Vaccination History: Post -Exposure Rabies ❑ Rabies Vaccinated current Vaccination: (current) ❑ Rabies Vaccinated (current) Vaccination: ❑ Not Rabies Vaccinated ❑ Received ❑ Not Rabies Vaccinated ❑ Received (not current) ❑ Not Received (not current) ❑ Not Received ❑ Unknown ❑ Unknown ❑ Unknown ❑ Unknown ` FLUORESCENT RABIES ANTIBODY TEST RESULTS: (for lab use only) Reported (initials)Date:'___( ❑ Positive (rabid) �)f�egative (not rabid) ❑ SpecimenJ— /` UnsatisfactoryComments: Revised 3/31/03 N�/1J Sl r �t{p%/svw`v.state.ma.us/dph/bls/viro.htm I -IL C� REQUEST FOR RABIES EXAMINATION State Laboratory Institute, Virology Division Rabies Laboratory (617) 983-6385, -6386, -6387 SUBMITTER Agency Street City/State/Zip _ Phone ( ) _ FORlLAS USE ONLY.- Date Received: Lab No: Owner or Person Who Found Animal City/State/Zip Phone( ) SPECIMEN INFORMATION (use reverse side for additional information) ANIMAL SPECIES; Breed Age ❑ Pet ❑ Stray ❑ Wild ❑ 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 ❑ Killed Method 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 ou ? In what COUNTY? EXPOSURE INFORMATION (use reverse side for additional information) PERSON(S) EXPOSED: Name Street City/State/Zip Phone ( ) Type of exposure: ❑ Bite ❑ 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 ANIMAL(S) EXPOSED: Name Species Owner _ Street City/State/Zip 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 booster after incident? ❑ Yes ❑ No ❑ Unknown