Form Micro201 "Request for Rabies Examination" - Vermont

What Is Form Micro201?

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

Form Details:

  • Released on August 9, 2018;
  • The latest edition provided by the Vermont 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 fillable version of Form Micro201 by clicking the link below or browse more documents and templates provided by the Vermont Department of Health.

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Download Form Micro201 "Request for Rabies Examination" - Vermont

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Vermont Department of Health Laboratory
Request for Rabies Examination
Mailing Address: PO Box 1125, Burlington, VT 05402-1125
Shipping and Drop Off Address: 359 South Park Drive, Colchester VT 05446
(802) 338-4724 or (800) 660-9997 in VT only
NOTE: All rabies testing requests must be pre-approved by Infectious Disease Epidemiology
Check here if request has been approved by calling: (802) 863-7240 or 1-800-640-4374 (available 24/7)
Submitter Information (e.g. Game Warden, Veterinarian)
Facility or Agency Name:
Last Name:
First Name:
Mailing Address:
City/Town:
State:
Zip Code:
Telephone Number (Day):
Telephone Number (Evening):
Shipping Address (If Different from Mailing Address):
Large Rabies Box Animal Kit (Indicate number needed):
Small Rabies Box Animal Kit (Indicate number needed):
Complainant Information (e.g. Animal Owner)
Last Name:
First Name:
Address:
City/Town:
State:
Zip Code:
Telephone Number (Day):
Telephone number (Evening):
Reason for Test:
Human Exposure *
Contact With Pet or Domestic Animal
Diagnostic
Surveillance
Human Exposure Information
Date of Exposure:
Type of Exposure:
Name of Person(s) Exposed:
Bite
Contact with Saliva/Nervous Tissue
Telephone Number of Exposed (Day):
Telephone Number of Exposed (Evening):
Animal Information
Animal Type:
Age of Bovine (If Applicable):
Animal/USDA ID Number:
Date of Death:
Town Captured/Found:
County Captured/Found:
State Captured/Found:
Latitude (USDA):
Longitude (USDA):
Porcupine Quills Present?
More than One Specimen in Box?
YES
NO
YES
NO
Comments (additional comments may be written on the back of this document):
*Human Exposure is only when wet saliva or nervous tissue from a suspect animal is directly introduced into open wounds and/or mucous
membranes (e.g. mouth, nose, eyes), or exposure to a bat where there is uncertainty of a bite.
Micro 201 Rev 9 August 2018
FILL OUT A SEPARATE FORM FOR EACH SPECIMEN
Page 1 of 1
Vermont Department of Health Laboratory
Request for Rabies Examination
Mailing Address: PO Box 1125, Burlington, VT 05402-1125
Shipping and Drop Off Address: 359 South Park Drive, Colchester VT 05446
(802) 338-4724 or (800) 660-9997 in VT only
NOTE: All rabies testing requests must be pre-approved by Infectious Disease Epidemiology
Check here if request has been approved by calling: (802) 863-7240 or 1-800-640-4374 (available 24/7)
Submitter Information (e.g. Game Warden, Veterinarian)
Facility or Agency Name:
Last Name:
First Name:
Mailing Address:
City/Town:
State:
Zip Code:
Telephone Number (Day):
Telephone Number (Evening):
Shipping Address (If Different from Mailing Address):
Large Rabies Box Animal Kit (Indicate number needed):
Small Rabies Box Animal Kit (Indicate number needed):
Complainant Information (e.g. Animal Owner)
Last Name:
First Name:
Address:
City/Town:
State:
Zip Code:
Telephone Number (Day):
Telephone number (Evening):
Reason for Test:
Human Exposure *
Contact With Pet or Domestic Animal
Diagnostic
Surveillance
Human Exposure Information
Date of Exposure:
Type of Exposure:
Name of Person(s) Exposed:
Bite
Contact with Saliva/Nervous Tissue
Telephone Number of Exposed (Day):
Telephone Number of Exposed (Evening):
Animal Information
Animal Type:
Age of Bovine (If Applicable):
Animal/USDA ID Number:
Date of Death:
Town Captured/Found:
County Captured/Found:
State Captured/Found:
Latitude (USDA):
Longitude (USDA):
Porcupine Quills Present?
More than One Specimen in Box?
YES
NO
YES
NO
Comments (additional comments may be written on the back of this document):
*Human Exposure is only when wet saliva or nervous tissue from a suspect animal is directly introduced into open wounds and/or mucous
membranes (e.g. mouth, nose, eyes), or exposure to a bat where there is uncertainty of a bite.
Micro 201 Rev 9 August 2018
FILL OUT A SEPARATE FORM FOR EACH SPECIMEN
Page 1 of 1