New Jersey Department of Health

Public Health Laboratories

REQUEST FOR RABIES EXAMINATION	FOR LAB USE ONLY
Lab Number
Date Received
SECTION I ‑ INFORMATION ON ANIMAL SUBMITTED
1. Type of Animal (e.g., dog, cat, raccoon, etc.)

2. Was Animal:

Pet Stray Wild	3. Date of Death

4. Cause of Death	5. Is/was pet vaccinated for Rabies?

Yes No
Euthanized Found Dead Other:
6. Animal Behavior Before Death (Check all that apply)
Apparently Normal	Lethargic or In Coma	Wobbly Gait	Not Afraid of Humans or Domestic Animals
Appeared Sick	Drooling Saliva	Paralysis	Other (Explain):
Aggressive	Overly Friendly	Wild Animal Out in Daylight	Unknown
7. Owner of Animal/Residence of Specimen Origin:
Name:
Tel. No.:	( )
Munic.:
Mailing Address:
8. Delivered By:
Name:
Tel. No.:	( )
Mailing Address:
9. Health Officer:
Name:
Fax No.:	( )
Mailing Address:
10. Attending Veterinarian (If applicable):
Name:
Tel. No.:	( )
Mailing Address:
11. Animal Control Officer (If applicable):
Name:
Tel. No.:	( )
Mailing Address:
SECTION II ‑ HUMAN EXPOSURE INFORMATION
12. Were any people bitten or exposed to this animal?

Yes‑Bitten Yes‑Exposed No
13. County/Municipality Where Exposure Occurred

14. Date of Exposure

15. Persons Bitten By or Exposed To Animal
Name:
Tel. No.:	( )
Munic.:
Mailing Address:
16. How did the exposure to this animal occur?

17. Has emergency rabies treatment of the exposed person been started?

Yes No Unknown
SECTION III ‑ ANIMAL EXPOSURE INFORMATION
18. Were any other animals bitten or exposed to this animal?

Yes‑Bitten Yes‑Exposed No	19. Type of Animal Exposed

20. Date Animal Exposed

21. Has exposed animal been vaccinated for rabies?

Yes No	22. How did the exposure occur?

23. Owner of Animal Exposed:
Name:
Tel. No.:	( )
Munic.:
Mailing Address:
VIR-16

APR 16

VIR-16, Request for Rabies Examination

Virology, public health and environmental laboratories, rabies examination, rabies testing, immunological laboratory services, zoonotic diseases, VIR-16

EWhite

2016-03-15

NJDOH