Bite/Exposure Reporting Form

RABIES is a serious, and many times deadly, disease that can be carried by several types of animals in Madison County.  It is incredibly important to report any and all animal bites to allow our staff to investigate and evaluate the risk of rabies exposure.  Whenever a person is bitten by a dog or other non-human mammal in Madison County, a report of the bite must be made within 24 hours to Madison County Public Health (MCPH). Under the Ohio Administrative Code 3701-3-28 (A) this report must be made by a treating or attending health care provider, by a licensed doctor of veterinary medicine with knowledge of the bite, or by the person bitten.  Please use the secure form below to report a bite to MCPH.

REPORTING AGENCY/PERSON INFORMATION

Type of Reporting Agency:
Hospital Physician Veterinarian Animal Shelter Law Enforcement EMS Citizen
Name of Reporting Agency:

Name of Person Reporting:    

Phone Number of Person Reporting:  
  


BITE/EXPOSURE INFORMATION

Date Bite Occurred:

Location Where Bite Occurred (full address if known):    

Place Where Animal Will Be Quarantined for 10 Days: 

Animal's Name:    

Type of Animal:    
Dog Cat Bat Rat Mouse Squirrel Rabbit Livestock Ferrett Other
Breed:    

Color:    

Sex:    
Male Female Unknown
Animal's Current Immunization Status:    
Current - rabies 1 year Current - rabies 3 year Expired Unknown
Date of Immunization    

Veterinarian:    

Veterinarian Phone:    



OWNER INFORMATION

Name of Animal's Owner:   
 
Phone Number of Animal's Owner:    

Address of Animal's Owner:    



VICTIM INFORMATION

Name of Victim:    

Phone Number of Victim:    

Address of Victim:    

Age of Victim:    

Parent or Guardian Name (if victim is a minor):   

Type and Specific Location of Injury:    

Exposure to Animal's Saliva?    
Yes No Unknown