Livestock Opioid Exposure Assessment Form
Use this form to report and assess possible opioid exposure in livestock, including the animals affected, suspected source, observed signs, and actions already taken.
Incident and Animal Identification
Date of incident or observation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Approximate time
Hour Minutes
AM
PM
AM/PM Option
Location or farm name
*
Livestock species affected
*
Cattle
Sheep
Goats
Pigs
Horses
Poultry
Other
Number of animals affected
*
Animal identifiers or group/pen identification
Exposure Details and Clinical Assessment
Suspected exposure source or route
*
Feed
Water
Medication error
Contaminated equipment
Unknown
Other
Estimated time since exposure
Observed clinical signs
*
Abnormal behavior
Respiratory depression
Sedation
Incoordination
Collapse
Other
Severity / urgency rating
*
Mild
1
2
3
4
5
6
7
8
9
Critical
10
1 is Mild, 10 is Critical
Per-animal observations
*
Overall concern level
*
Low
Moderate
High
Critical
Actions Taken and Follow-up
Actions already taken
*
Isolated animal
Contacted veterinarian
Removed suspected source
Monitoring only
Other
Veterinary attention
*
Requested
Provided
Not yet requested
Not needed
Current contact name
*
First Name
Middle Name
Last Name
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred follow-up method
*
Please Select
Phone
Text message
Email
In person
Other
Additional notes
Recommended next steps
Submit Assessment
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