Form CDPH102 "Animal Rabies Case Report" - California

What Is Form CDPH102?

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

Form Details:

  • Released on October 1, 2011;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CDPH102 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form CDPH102 "Animal Rabies Case Report" - California

332 times
Rate (4.8 / 5) 20 votes
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY
EDMUND G. BROWN JR., Governor
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
VETERINARY PUBLIC HEALTH SECTION
MS 7308, PO BOX 997377
SACRAMENTO, CA 95899-7377
(916) 552-9740
(916) 552-9725 FAX
VETPH@CDPH.CA.GOV
ANIMAL RABIES CASE REPORT
I. TESTING LABORATORY: Please complete Section I, fax or email to the Veterinary Public Health Section using the contact
information above, and forward the original to the County Rabies Investigator.
Laboratory:
Date Received:
Sample Submitted By:
Phone:
Animal Species:
Sample Submitted:
Animal
Head
Brain
Other
Lab Specimen #:
Laboratory Test Results:
Date Reported
FRA Test:
Positive
Unsatisfactory
Pending
Not Done
VRDL Referral:
Positive
Unsatisfactory
Pending
Not Done
VRDL Lab #:
Humans Exposed (bitten or significant saliva contact?)
Yes
No
Unknown
Other Animals Exposed (bitten or direct contact)?
Yes
No
Unknown
II. RABIES EPIDEMIOLOGIC INVESTIGATION: Please complete Section II and fax or email to the Veterinary Public Health
Section using the contact information above.
Date Animal Found:
Type of Rabid Animal:
Pet
Livestock
Stray
Wild
Address/Location Where Found:
Cause of Death:
Euthanized
Died in Quarantine
Killed- How?
Clinical Impressions:
Dumb
Furious
Found Dead
Unknown
Other
Other Animals Exposed?
Yes
No
Unknown
Vaccinated at Time of Exposure?
Yes
No
Species:
Number:
Bitten
Direct Contact
Unknown
Please Describe Details/Disposition of Exposed Animals (i.e. revaccinated, quarantined, euthanized, etc.)
Humans Exposed?
Yes
No
Unknown
Number:
Bitten
Scratched
Saliva Contact Only
Attack:
Unprovoked
Provoked? (includes attempts to help injured animals)
Name, Address, & Phone of Exposed Persons:
Persons Treated?
Explain if Exposed but Not Treated:
Number:
County Personnel Reporting:
Name:
Date Reporting:
Title:
County Agency:
Address:
Phone:
Email:
CDPH 102 (10/11)
Page 1 of 2
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY
EDMUND G. BROWN JR., Governor
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
VETERINARY PUBLIC HEALTH SECTION
MS 7308, PO BOX 997377
SACRAMENTO, CA 95899-7377
(916) 552-9740
(916) 552-9725 FAX
VETPH@CDPH.CA.GOV
ANIMAL RABIES CASE REPORT
I. TESTING LABORATORY: Please complete Section I, fax or email to the Veterinary Public Health Section using the contact
information above, and forward the original to the County Rabies Investigator.
Laboratory:
Date Received:
Sample Submitted By:
Phone:
Animal Species:
Sample Submitted:
Animal
Head
Brain
Other
Lab Specimen #:
Laboratory Test Results:
Date Reported
FRA Test:
Positive
Unsatisfactory
Pending
Not Done
VRDL Referral:
Positive
Unsatisfactory
Pending
Not Done
VRDL Lab #:
Humans Exposed (bitten or significant saliva contact?)
Yes
No
Unknown
Other Animals Exposed (bitten or direct contact)?
Yes
No
Unknown
II. RABIES EPIDEMIOLOGIC INVESTIGATION: Please complete Section II and fax or email to the Veterinary Public Health
Section using the contact information above.
Date Animal Found:
Type of Rabid Animal:
Pet
Livestock
Stray
Wild
Address/Location Where Found:
Cause of Death:
Euthanized
Died in Quarantine
Killed- How?
Clinical Impressions:
Dumb
Furious
Found Dead
Unknown
Other
Other Animals Exposed?
Yes
No
Unknown
Vaccinated at Time of Exposure?
Yes
No
Species:
Number:
Bitten
Direct Contact
Unknown
Please Describe Details/Disposition of Exposed Animals (i.e. revaccinated, quarantined, euthanized, etc.)
Humans Exposed?
Yes
No
Unknown
Number:
Bitten
Scratched
Saliva Contact Only
Attack:
Unprovoked
Provoked? (includes attempts to help injured animals)
Name, Address, & Phone of Exposed Persons:
Persons Treated?
Explain if Exposed but Not Treated:
Number:
County Personnel Reporting:
Name:
Date Reporting:
Title:
County Agency:
Address:
Phone:
Email:
CDPH 102 (10/11)
Page 1 of 2
STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY
EDMUND G. BROWN JR., Governor
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
VETERINARY PUBLIC HEALTH SECTION
MS 7308, PO BOX 997377
SACRAMENTO, CA 95899-7377
(916) 552-9740
(916) 552-9725 FAX
VETPH@CDPH.CA.GOV
ANIMAL RABIES CASE REPORT
Domestic Animal Information Form
Please complete this page if the rabid animal was a domestic dog, cat, horse, cattle, goat, sheep, etc.
Owner's Contact Information:
Name:
Home Phone:
Address:
Work Phone:
Domestic Animal's Information:
Sex:
Male
Female
Name:
Altered?
Yes
No
Unknown
Breed:
Licensed?
Yes
No
Unknown
Age (estimate for strays):
Date of First Signs:
Date of Death:
Vaccination Date:
Rabies Vaccinated?
Yes
No
Expired
Administering DVM:
Product Name:
Manufacturer:
Lot Number:
Animal's Environment?
Urban
Suburban
Rural
Other
If the animal was originally from another country/state, please specify:
Veterinarian's Information:
DVM's Name:
Seen by a DVM?
Yes
No
Date of Initial Visit:
DVM's Phone:
Initial Diagnosis/Ruleout:
DVM's Email:
For The 6-Month Period Before the Animal's Death:
How many hours per day was the animal kept outside?
Kept on a lead or in a pen while outside?
Yes
No
Unknown
Kept indoors or in a pen at night?
Yes
No
Unknown
Missing for more than 24-hours?
Yes
No
Unknown
Observed fighting/playing with any wild animal?
Yes
No
Unknown
Observed fighting/playing with a confirmed rabid animal?
Yes
No
Unknown
Exhibited signs of an unexplained lameness?
Yes
No
Unknown
Unexplained wound or cut?
Yes
No
Unknown
Describe location and type of injury:
Used for hunting wild animals?
Yes
No
Unknown
Traveled out-of-state or out-of-country?
Yes
No
Unknown
Specify destination & date(s):
Comments:
CDPH 102 (10/11)
Page 2 of 2
Page of 2