Form FDACS-09125 "Arboviral Encephalitis Case Information Form" - Florida

What Is Form FDACS-09125?

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

Form Details:

  • Released on May 1, 2013;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • 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 FDACS-09125 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-09125 "Arboviral Encephalitis Case Information Form" - Florida

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Contact:
Florida Department of Agriculture & Consumer Services
Division of Animal Industry
Equine Programs Office
407 S. Calhoun St.
Bureau of Animal Disease Control
Tallahassee, FL 32399-0800
850-410-0900 Fax: 850-410-0919
ARBOVIRAL ENCEPHALITIS
NICOLE "NIKKI" FRIED
www.FDACS.gov/ai
CASE INFORMATION FORM
COMMISSIONER
585.145, Florida Statutes
Note: All documents and attachments submitted with this request are subject to public review pursuant to Chapter 119, F.S.
Submitter: Please send this completed form along with collected samples to the Bronson Animal
FOR LAB USE ONLY
Disease Diagnostic Laboratory at:
2700 N John Young Pkwy, Kissimmee, FL 34741 Phone (321) 697-1400
If submitting split samples, send copies of completed form (both pages) to each laboratory used. If samples are not being submitted,
please send the completed form to Equine Programs Office, Division of Animal Industry, Fax 850-410-0919. Hard copies can be
mailed to the address shown above.
County
Date Reported
Premises GPS
5 decimal digits)
(
Premises ID Number
Latitude
Longitude
FDACS/USDA Veterinarian(s) or Inspector(s) Assigned:
Name
Title/Occupation
Business/Affiliation
Mailing Address
Physical Address (if different)
Phone #
Fax #
Mobile #
Pager #
Email
Name
Title/Occupation
Premises/Farm Name
Mailing Address
Physical Address (if different) (Where Horse Resides)
Phone #
Fax #
Mobile #
Pager #
Email
FDACS-09125 Rev. 05/13
Page 1 of 2
Contact:
Florida Department of Agriculture & Consumer Services
Division of Animal Industry
Equine Programs Office
407 S. Calhoun St.
Bureau of Animal Disease Control
Tallahassee, FL 32399-0800
850-410-0900 Fax: 850-410-0919
ARBOVIRAL ENCEPHALITIS
NICOLE "NIKKI" FRIED
www.FDACS.gov/ai
CASE INFORMATION FORM
COMMISSIONER
585.145, Florida Statutes
Note: All documents and attachments submitted with this request are subject to public review pursuant to Chapter 119, F.S.
Submitter: Please send this completed form along with collected samples to the Bronson Animal
FOR LAB USE ONLY
Disease Diagnostic Laboratory at:
2700 N John Young Pkwy, Kissimmee, FL 34741 Phone (321) 697-1400
If submitting split samples, send copies of completed form (both pages) to each laboratory used. If samples are not being submitted,
please send the completed form to Equine Programs Office, Division of Animal Industry, Fax 850-410-0919. Hard copies can be
mailed to the address shown above.
County
Date Reported
Premises GPS
5 decimal digits)
(
Premises ID Number
Latitude
Longitude
FDACS/USDA Veterinarian(s) or Inspector(s) Assigned:
Name
Title/Occupation
Business/Affiliation
Mailing Address
Physical Address (if different)
Phone #
Fax #
Mobile #
Pager #
Email
Name
Title/Occupation
Premises/Farm Name
Mailing Address
Physical Address (if different) (Where Horse Resides)
Phone #
Fax #
Mobile #
Pager #
Email
FDACS-09125 Rev. 05/13
Page 1 of 2
Florida Department of Agriculture and Consumer Services
Division of Animal Industry/Office of the State Veterinarian
Arboviral Encephalitis
Case Information Form (continued)
Name/Animal Identification
Date of onset of clinical symptoms
Breed
Age
Sex (Male/Female/Gelding)
Vaccination Status (History)
Status of Horse:
Alive
Dead
Critical
Date of Death:
Buried?
Yes
No
Recovering as of (Date):
Showing clinical symptoms?
Yes
No
Method of Death: _______ Natural causes
______ Euthanasia ______ Other:
Has the horse traveled off premises, in the past 4 weeks?
Yes
No
If Yes, describe (when and where).
Number of samples taken.
Date samples taken:
Samples submitted to FDACS Kissimmee Diagnostic Laboratory
Sample type:
Blood
Brain
Other:
Date Sent:
Samples submitted to USDA National Veterinary Services Laboratory (NVSL)
Sample type:
Blood
Brain
Other:
Date Sent:
Samples submitted to Florida DOH Laboratory
Sample type:
Blood
Brain
Other:
Date Sent:
History:
Clinical Presentation:
Incoordination
Other:
Apprehension
Weakness of Hind Limbs
Depression
Inability to Stand
Elevated Temperature
Aimless Wandering
Head Shaking
Head Pressing
Muscle Twitching
Listlessness
Comments/Additional Information:
Attach additional pages as needed.
FDACS-09125 Rev. 05/13
Page 2 of 2
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