New Jersey Department of Health

ZOONOTIC DISEASE INCIDENT REPORT	FOR STATE USE ONLY
Report Number
LOCAL HEALTH DEPARTMENT INFORMATION
Name of Local Health Department

Date of Report

Name of Contact Person

Telephone Number

Street Address

PO Box, Apt., Suite

Cell Phone Number

City

Zip Code

Email Address

PERSON REPORTING
Name (First, Last)

Affiliation (Vet, etc.)

Telephone Number

Street Address

PO Box, Apt., Suite

Cell Phone Number

City

Zip Code

Email Address

ANIMAL OWNER INFORMATION
Name of Owner (First, Last)

Telephone Number

Street Address

PO Box, Apt., Suite

Cell Phone Number

City

Zip Code

Email Address

ANIMAL FACILITY INFORMATION (IF APPLICABLE)
Name of Animal Facility

Telephone Number

Street Address

PO Box, Apt., Suite

Cell Phone Number

City

Zip Code

Email Address

DISEASE REPORT DETAILS
Disease

Anthrax

Avian Chlamydiosis

(Chlamydophila psittaci)

Brucella canis

Campylobacteriosis

Escherichia coli shiga toxin

producing strains (STEC)

Leishmaniasis

Leptospirosis

Lymphocytic Choriomeningitis

Mycobacterium tuberculosis

Plague (Yersinia pestis)

Q Fever (Coxiella burnetti)

Salmonellosis

Tularemia (Franscisella tularensis)

Other: _________________________	Check if appropriate:

Outbreak

(observed cases in excess of expected)

Disease Agent is Unknown

Number of Cases: ______

ANIMALS HOUSED ON PREMISES

(Please provide the following information regarding additional animals on the premises or in the household)
Species	Number Housed on Premises	Number Sick	Additional Information
Dog
Cat
Pet Birds
Ferret
Other:

CASE SPECIFIC INFORMATION

[Complete for index (first) case on premises or in outbreak; use Continuation Sheets for additional cases.]
Animal Name (or ID)

Animal Age

Animal Sex

Animal Breed

Animal Color

Illness Onset Date

Clinical Signs

Date of First Visit to Vet

Name, Address and Telephone Number of Veterinarian (if not provided on Page 1)

Relevant History

Treatment

Outcome

Survived Euthanized Died	Date

Postmortem Exam Performed?

Yes No	If Yes, Date Performed

LABORATORY TEST RESULTS
Name of Laboratory

Organism/Agent	Lab Result/Value	Type of Test Performed	Specimen Type	Date Obtained
Comments

COMPLETE THIS SECTION ONLY IF ANIMAL WAS PURCHASED WITHIN SIX (6) MONTHS OF DISEASE ONSET
Place Animal Purchased or Acquired

Date Animal Purchased or Acquired

Street Address

Telephone Number

City

State

Zip Code

Type of Facility

Kennel Pet Shop Shelter Pound Private Individual (specify): _________________________
HUMAN EXPOSURE / ILLNESS
Number of Persons Exposed to Animal

Number of Persons Ill

CDRSS Case ID’s of Human Cases Linked to Animal Case

Name, Address and Telephone Number of Physician (if seen)

Comments / Updates

CASE SPECIFIC INFORMATION

(Complete a separate form for each sick animal.)
Animal Name (or ID)

Animal Age

Animal Sex

Animal Breed

Animal Color

Illness Onset Date

Clinical Signs

Date of First Visit to Vet

Relevant History

Treatment

Outcome

Survived Euthanized Died	Date

Postmortem Exam Performed?

Yes No	If Yes, Date Performed

LABORATORY TEST RESULTS
Name of Laboratory

Organism/Agent	Lab Result/Value	Type of Test Performed	Specimen Type	Date Obtained
Comments

ZOONOTIC DISEASE INCIDENT REPORT

(Continued)

CDS-32

AUG 12	Page 3 of 4 Pages.

AUG 12	Page 4 of 4 Pages.

CONTINUATION SHEET

CDS-32, Zoonotic Disease Incident Report

CDS-32, CDS, zoonotic disease, animal, infectious, zoonotic, animal health, veterinary health

ewhite

2012-03-19

NJDOH