Form VIR-16 "Request for Rabies Examination" - New Jersey

What Is Form VIR-16?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2016;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form VIR-16 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form VIR-16 "Request for Rabies Examination" - New Jersey

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FOR LAB USE ONLY
New Jersey Department of Health
Lab Number
Public Health Laboratories
Date Received
REQUEST FOR RABIES EXAMINATION
SECTION I - INFORMATION ON ANIMAL SUBMITTED
1. Type of Animal (e.g., dog, cat, raccoon, etc.)
2. Was Animal:
3. Date of Death
Pet
Stray
Wild
4. Cause of Death
5. Is/was pet vaccinated for Rabies?
Euthanized
Found Dead
Other:
Yes
No
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):
Tel. No.: (
)
Name:
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?
19. Type of Animal Exposed
20. Date Animal Exposed
Yes-Bitten
Yes-Exposed
No
21. Has exposed animal been vaccinated for rabies?
22. How did the exposure occur?
Yes
No
23. Owner of Animal Exposed:
(
)
Name:
Tel. No.:
Munic.:
Mailing Address:
VIR-16
APR 16
FOR LAB USE ONLY
New Jersey Department of Health
Lab Number
Public Health Laboratories
Date Received
REQUEST FOR RABIES EXAMINATION
SECTION I - INFORMATION ON ANIMAL SUBMITTED
1. Type of Animal (e.g., dog, cat, raccoon, etc.)
2. Was Animal:
3. Date of Death
Pet
Stray
Wild
4. Cause of Death
5. Is/was pet vaccinated for Rabies?
Euthanized
Found Dead
Other:
Yes
No
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):
Tel. No.: (
)
Name:
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?
19. Type of Animal Exposed
20. Date Animal Exposed
Yes-Bitten
Yes-Exposed
No
21. Has exposed animal been vaccinated for rabies?
22. How did the exposure occur?
Yes
No
23. Owner of Animal Exposed:
(
)
Name:
Tel. No.:
Munic.:
Mailing Address:
VIR-16
APR 16