Animal Bites Referral

Date of Report Taken

Report Taken By

First Name

Last Name

Title/Position

Agency

Agency Address

Street Address

City

State/Province

Postal Code

Agency Email

Agency Phone

Phone Number

Other Phone

Phone Number

Person Bitten

First Name

Last Name

Middle Name

Birthdate

Age

If Minor, Parent's Name

First Name

Last Name

Address

Street Address

City

State/Province

Postal Code

Phone

Phone Number

ICR# (Optional)

Date Bitten

Time Bitten

Location of Bite(s)

Skin Broken

Yes

No

Explain Situation

File Upload (Optional for Additional Information)

Type and Description of Animal

Animal Status

Domestic

Stray

Wild

Unknown

Animal has had rabies vaccine

Yes

No

Unknown

Animal is available for...

10 days observation

Testing

Animal not available

Unknown

Current Location of Animal

ANIMAL BITES REFERRAL FORM

ANIMAL BITE REFERRAL TO ST. LOUIS COUNTY PUBLIC HEALTH

PERSON BITTEN INFORMATION

DESCRIPTION OF INCIDENT

ANIMAL INFORMATION