New Jersey Department of Health

Infectious and Zoonotic Diseases Program

P. O. Box 369, Trenton, NJ 08625-0369

Fax No.: 609-588-3894

REPORT OF KNOWN OR SUSPECTED

AVIAN CHLAMYDIOSIS (PSITTACOSIS)
Date of Report

I. REPORTING VETERINARIAN
Name

Telephone Number

Agency

Address

II. BIRD OWNER
Name

Telephone Number

Address

Other Birds on Premises?

Yes	No	Exposure History to Other Birds?

Yes	No	If yes, Date and Site of Exposure:

III. SOURCE OF BIRD
Type of Bird

Date Purchased or Acquired

Where Purchased/Acquired (Name of Pet Shop, Aviary or Person)

Telephone Number

Address

IV. CLINICAL SIGNS
Date of Onset of

Signs of Illness

Signs (Check all that apply)

Bird Exhibiting No Symptoms	Nasal Discharge	Diarrhea

Anorexia	Ocular Discharge	Dypsnea

Ruffled Feathers	Lethargy	Green/Yellow Urates
Emaciation	Other
V. DIAGNOSTIC TEST RESULTS
Serology:	Lab Where Test Performed:
Complement Fixation Titer	Elementary Body Agglutination	Immunofluorescent Antibody Titer
Results:
Pathology:	Lab Where Test Performed:
Autopsy Whole Bird	Results:
Tissue Samples	Results:
Culture:	Lab Where Test Performed:
Specimen:	Results:
Test for Antigen:	Lab Where Test Performed:
Enzyme-Linked Immunosorbent Assay (ELISA)	Results:
Immunofluorescent Antibody Test (IFA)	Results:
Polymerase Chain Reaction (PCR)	Results:
Other:
VI. ZOONOTIC POTENTIAL
Has veterinarian discussed zoonotic

potential of disease with bird owners?	Yes	No	Are any persons exposed showing

signs of Psittacosis-like illness?	Yes	No
List Names of Ill Persons:

CDS-18

AUG 12

CDS-18, Report of Known or Suspected Avian Chlamydiosis (Psittacosis)

cds-18, bird flu, chlamydiosis, veterinarian, psittacosis, zoonotic diseases

EWhite

2012-03-19

NJDOH