Free ANIMAL_BITES_14072 - Indiana

Official Indiana Animal Bites Report
Indiana State Department of Health State Form 14072 (R3/4-04)
Reporting Agency Case Number Incident Location Address Reported by (name) Reported by (phone) Reporting Agency Bite Classification

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County

(see reverse side of this page to classify)

Exposure Date Reported Date

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Reported Time

Incident
Received by (name)

On

Off Property Juvenile Adult

Victim Type (circle 2) Human Animal

Release Date

VICTIM INFORMATION
Person bitten (if animal victim, use this space for animal victim's owner): Owner of Animal:
Last

OWNER INFORMATION
First City Work Telephone Color/Markings Other Name Sex M Neutered Y Prior Incidents Mid. Zip Date of Birth Sex M

Last Name

Street Address Home Telephone

F

Victim

First Name Date of Birth
Street Address

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City Zip

Sex

M

F

Biting Animal Dog Cat Breed

F N

Parent if victim is a juvenile:
Last First City Mid. Zip Telephone Home: Work: Vaccine Date (rabies)

Animal's Veterinarian Rabies Vaccine Date Y N Rabies Tag Number Location of Quarantine Name Sex M F Released from Quarantine by (name): Owner release card (date received): Released from shelter quarantine (date): Lab #/Result: Date of Quarantine Quarantined by (name)

Parent

Street Address

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License Number

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Microchip Number Citation issued? Y N

Animal

If animal victim:
Breed/Species Color/Markings

Release Date

Incident & Circumstances

(if animal victim) Quarantined? Yes No

Time of bite

Treating Physician (or veterinarian) Name: Telephone:

Location on Body and Extent of Injury: Victim's statement of incident (animal owner if animal victim):

Animal owner's statement of incident:

State Department of Health required information (must be completed):
Species (fill in the correct biting species): Bat Dog Hamster Cattle Ferret Horse Cat Chipmunk Fox Gerbil Mouse Rabbit Raccoon Rat Squirrel Other

Circumstances: Animal confined (indoors, penned, tethered, or on leash) Animal not confined (stray, roaming, etc.) Wild Animal Unknown Provoked Other Body destroyed Head sent to ISDH Lab Other Unknown Unprovoked

If Other, specify Did the animal exhibit any of the following: Convulsions Aggression Inability to eat/drink Excessive salivation Paralysis Depression

Action taken with animal: No Action Escaped/not found Pet quarantined (see dates above)
(dog, cat, ferret only)

I, the undersigned, have received a copy of the quarantine guidelines, have read them, and understand them. I agree to comply with all provisions of the quarantine guidelines and understand that noncompliance may result in seizure of my pet if it is in home quarantine or loss of my pet if it is not properly claimed at the end of the quarantine period from the quarantining agency. Witness___________________________________ Date __________________ Signature__________________________________________

DISTRIBUTION: White - Enforcing Agency, Canary - Local Health Department, Pink - Owner

Incident

Quarantine

Animal

Telephone Home: Work:

Owner

Animal Bite Classification System ­ Proper Use
Bites are classified alphanumerically. The alpha designation indicates the victim, geographic location, and if the animal has bitten previously. The numeric designation indicates severity with (1) the least severe and (5) the most severe. Section I ­ Victim H = Human D = Other animal (domestic) W = Other animal Section II ­ Confined/Stray C = Confined at the time of the bite S = Stray, roaming, off property, or not legally restrained Section III ­ Repeat Biter R = Repeat biter, previous information on file O = No previous bites Section IV ­ Bite Severity 1. Minor Scratch 2. Minor, punctures 4 or less 3. Moderate, punctures 4. Severe, punctures (4 or more) deep may include crushing or tears from shaking 5. Death

Example: H/C/R/3 = A bite to a human; the animal was legally confined at the time of the bite; the animal has bitten previously, and this is a bite of moderate severity.

Initial Owner/Victim Contact ­ Action for Quarantine
Location: Date: Officer: Description: Results:

Failed Quarantine (indicate reason):

Victim contacted on the 10th day: Date: Agent contacting victim: Individual spoke with:

Reserved space for office use:

QUARANTINE GUIDELINES AND INFORMATION If your animal has been quarantined at a shelter or local veterinarian, the required date to pick up the pet is___________________________________. If you do not reclaim your pet from (or make arrangements with) the quarantining agency by the end of the business day of the date entered above, and pay appropriate fees at the time of reclaim, the animal will become the property of the agency at that time. The disposition of the animal may be determined at that time by the quarantining agency.

INSTRUCTIONS FOR A HOME QUARANTINE
(Location of quarantine is at the discretion of the quarantining agency.)

1. Facility used for confinement shall ensure an escape-proof environment subject to unannounced periodic spot checks by the animal control officer or local health officer. The animal shall be confined inside a structure, not on a chain or in a fenced yard. Diagrams for the construction of cat and dog isolation cages are available if such is recommended by the animal control officer or local health officer. 2. The animal shall not leave the quarantine premises for any reason. The animal shall not have contact with humans or other animals for the 10-day period, with the exception of the primary caretaker. 3. At the first sign of illness in the animal, the owner shall notify the quarantining agency. Symptoms to watch for include fever, loss of appetite, excessive irritability, unusual vocalization, change in behavior, restlessness, jumping at noises, trouble walking, excessive salivation, tremors, convulsions, paralysis, stupors, or unprovoked aggression. 4. At the end of the 10-day quarantine period, the owner is responsible for contacting the quarantining agency to report the health status of the animal. 5. If these guidelines cannot be met or are violated at any time during the quarantine, the animal will be seized and the 10-day quarantine will be completed at the department of animal control shelter or a facility designated by the local health officer. 6. When a pet has been exposed to rabies and it is not vaccinated, euthanasia is recommended. Alternatively, the owner has the option of arranging for a six-month quarantine at the owner's expense. This is due to the special public health risks associated with these animals (i.e., those potentially incubating rabies) and the need to prevent human and other animal exposures from occurring should rabies symptoms develop.

MEDICAL INFORMATION FOR VICTIMS AND PET OWNERS Questions regarding medical treatment and advice should be directed to your family physician. Concerns regarding tetanus toxoid and/or rabies prophylaxis may be addressed by your physician or the local health officer. If your pet has been injured by another animal, contact your veterinarian for appropriate treatment.