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- "Reportable Disease Case Report Form" - Utah
"Reportable Disease Case Report Form" - Utah
Reportable Disease Case Report Form is a legal document that was released by the Utah Department of Agriculture and Food - a government authority operating within Utah.
Form Details:
- The latest edition currently provided by the Utah Department of Agriculture and Food;
- Ready to use and print;
- Easy to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Utah Department of Agriculture and Food.
Download "Reportable Disease Case Report Form" - Utah
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1REPORTABLE DISEASE CASE REPORT FORM
Utah Department of Agriculture and Food
Division of Animal Industry
Date: ___________________________________ Recorded by: __________________
Veterinarian: _____________________________ Phone: _______________________
Owner: _________________________________________________________________
Address: ________________________________________________________________
City: ________________________________
Phone: _______________________
SPECIES: _________________________________
Number of Animals Involved: _________________
Age: ______ Breed: _________________ Sex: _____________
Name or ID Number: ______________________________________________________
Address where animal is located: ____________________________________________
DISEASE: ______________________________________________________________
TESTS: _________________________________________________________________
Other Tests: _____________________________________________________________
Treated:
YES
NO
Euthanized:
YES
NO
Other animal(s) on premises: ________________________________________________
TO REPORT:
Utah State Department of Agriculture and Food
Division of Animal Industry
350 N Redwood Rd, P.O. Box 146500
Salt Lake City, UT 84114-6500
Phone: (801) 538-7161
FAX:
(801) 538-7169
REPORTABLE DISEASE CASE REPORT FORM
Utah Department of Agriculture and Food
Division of Animal Industry
Date: ___________________________________ Recorded by: __________________
Veterinarian: _____________________________ Phone: _______________________
Owner: _________________________________________________________________
Address: ________________________________________________________________
City: ________________________________
Phone: _______________________
SPECIES: _________________________________
Number of Animals Involved: _________________
Age: ______ Breed: _________________ Sex: _____________
Name or ID Number: ______________________________________________________
Address where animal is located: ____________________________________________
DISEASE: ______________________________________________________________
TESTS: _________________________________________________________________
Other Tests: _____________________________________________________________
Treated:
YES
NO
Euthanized:
YES
NO
Other animal(s) on premises: ________________________________________________
TO REPORT:
Utah State Department of Agriculture and Food
Division of Animal Industry
350 N Redwood Rd, P.O. Box 146500
Salt Lake City, UT 84114-6500
Phone: (801) 538-7161
FAX:
(801) 538-7169
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