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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.
!["Reportable Disease Case Report Form" - Utah](https://data.templateroller.com/pdf_docs_html/1921/19211/1921131/page_1_thumb.png ""Reportable Disease Case Report Form" - Utah")
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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DD Form 2923 "Privacy Act Data Cover Sheet"
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