Rabies Specimen History - Wadsworth Center

Rabies Specimen History - Wadsworth Center

Print... Save As... Clear Form NEW YORK STATE DEPARTMENT OF HEALTH Wadsworth Center, Griffin Laboratory 5668 State Farm Road, Slingerlands, NY 12159...

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NEW YORK STATE DEPARTMENT OF HEALTH Wadsworth Center, Griffin Laboratory 5668 State Farm Road, Slingerlands, NY 12159

NYS Lab Number Date Received

Rabies Specimen History FOR LABORATORY USE ONLY

Animal being submitted for testing 1. 2. 3. 4. 5. 6. 7. 8.

Submitter’s specimen number (optional)

Species: Owned Wild (feral) or stray Age: Adult Juvenile Unknown Sex: Male Female Unknown Rabies vaccination status: Current Not current Unvaccinated Unknown Was the animal sick or acting strangely? Yes No Unknown Signs of rabies (check all that apply): Neurologic disorder Paralysis Difficulty swallowing Other (describe): Date of death: If killed, how? Owner or complainant (REQUIRED):

Unusual aggression

Name

Daytime phone number

Location where the submitted animal was found or the exposure occurred House number and street

City

State

ZIP

Town (required)

Longitude (East-West) (optional)

Nearest cross street If public place (example: school, children’s camp, church), provide name County

Latitude (North-South) (optional)

Please check this box if Emergency testing - outside of regular business hours is requested for this specimen. Contact the New York State Bureau of Communicable Disease Control for approval at: (518) 473-4439. Human and domestic animal exposure to the submitted animal No Unknown If yes, provide the date of the bite 9. Was any person bitten by the animal? Yes 10. Has rabies post exposure prophylaxis (PEP) been initiated? Yes No Unknown If yes, provide the date 11. Was any person scratched by the animal or had contact with its saliva or nervous tissue? Yes No Unknown 12. If the animal is a bat, is there a reasonable probability that any person was exposed? Yes No Unknown Example: a bat was found near an unattended child or a person who was asleep and unable to tell if they were bitten. 13. Did any domestic animal have contact with the submitted animal? Yes No Unknown Species of exposed domestic animal(s) Specimen prepared by (for drop-off specimens, the submitter) Agency

Daytime phone number

Address

For questions regarding packaging and shipping of specimens please contact the Rabies Laboratory at (518) 485-6464. Comments (explain exposures):

THE COUNTY HEALTH DEPARTMENT MUST BE NOTIFIED OF ALL HUMAN AND DOMESTIC ANIMAL EXPOSURES FOR LABORATORY USE ONLY The fluorescent antibody test was negative for evidence of rabies. The specimen was unsatisfactory for examination due to: decomposition Other EVIDENCE OF RABIES WAS FOUND BY THE FLUORESCENT ANTIBODY TEST. DOH-487 (7/13)

inappropriate tissue

mutilation

other