ARKANSAS DEPARTMENT OF HEALTH Public Health Laboratory Rabies Examination Form Submitter’s Information Owner’s Information Agency Name Name Address Address City State Zip City State Zip County Phone County Phone Person Bitten by this Animal Animal Bitten by this Submitted Animal Name Owner Kind of Animal Address Address City State Zip City State Zip County Phone County Phone INFORMATION ON SUBMITTED ANIMAL At Owner’s Home Location Submitted Animal Specify Kind of Animal County Address City State Zip Date Animal Died __/__/______ Was Submitted Animal Bitten by Another Animal? Was Submitted Animal Vaccinated Against Rabies? Name Phone Information about the veterinarian who observed the animal Address City State Zip Noted Symptoms: _________________________ _________________________ (Do LABORATORY USE ONLY not write in this section) Microscopic Exam of Brain Material for Rabies was: Negative Positive Unsatisfactory Date / Time ____/____/____ Received ____:____ Test Completed on ____/_ _/__ Specimen Number Results Reported Analyst to on ____/____/__ Ship via HL-12 (R 2/09)
ARKANSAS DEPARTMENT OF HEALTH Public Health Laboratory Rabies Examination Form Submitter’s Information Owner’s Information Agency Name Name Address Address City State Zip City State Zip County Phone County Phone Person Bitten by this Animal Animal Bitten by this Submitted Animal Name Kind of Animal Owner Address Address City State Zip City State Zip County Phone County Phone INFORMATION ON SUBMITTED ANIMAL Specify Kind of Animal Location Submitted Animal At Owner’s Home Address County City State Zip Date Animal Died __/__/______ Was Submitted Animal Bitten by Another Animal? Was Submitted Animal Vaccinated Against Rabies? Information about the veterinarian who observed the animal Name Phone Address City State Zip Noted Symptoms: _________________________ _________________________ LABORATORY USE ONLY (Do not write in this section) Microscopic Exam of Brain Material for Rabies was: Negative Positive Unsatisfactory Specimen Number Date / Time Received ____/____/____ ____:____ Test Completed on ____/_ _/__ Ship via Analyst Results Reported to on ____/____/__ HL-12 (R 2/09)
Rabies_Form_(Revised).docx