New Jersey Department of Health

OUT-OF-STATE ANIMAL BITE REPORT

Report Received By (Name)

Date

Time

Reported By

Telephone Number

Animal Name (or ID)

Animal Type

Animal Age

Animal Sex

Animal Breed

Animal Color

Date of Bite

Geographic Location of Bite

PERSON BITTEN
Name of Person Bitten (First, Last)

Date of Birth

Telephone Number

Street Address

PO Box, Apt., Suite

Cell Phone Number

City

State

Zip Code

Email Address

Is patient a minor?

Yes No	If Yes, Name and Telephone Number of Parent/Guardian

ANIMAL OWNER INFORMATION
Name of Animal Owner (First, Last)

Telephone Number

Street Address

PO Box, Apt., Suite

Cell Phone Number

City

State

Zip Code

Email Address

Name, Address and Telephone Number of Veterinarian

MEDICAL CARE PROVIDER
Name of Medical Care Provider

Telephone Number

Street Address

PO Box, Apt., Suite

Cell Phone Number

City

State

Zip Code

Email Address

Was rabies treatment started?

Yes No	If Yes, Date Treatment Started

CIRCUMSTANCES OF THE BITE
Location on Body where Bite Occurred

NOTES

CDS-31

AUG 12

CDS- 31, Out of State Animal Bite Report

CDS-31, communicable disease, zoonotic disease, infectious, animal bite, out of state, bite report, cds

ewhite

2012-03-19

NJDOH