Zoonotic Disease Report Form
Use this form to report a zoonotic disease incident. Please provide clear and accurate information to assist with follow-up and monitoring.
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
*
Animal Species Involved
*
Please Select
Dog
Cat
Livestock (e.g., cattle, sheep, pigs)
Wildlife
Bird
Rodent
Other
Suspected Disease
*
Please Select
Rabies
Salmonellosis
Brucellosis
Leptospirosis
Q Fever
Avian Influenza
Other
Brief Description of Incident
*
Number of Animals Affected
Was there direct human contact?
*
Yes
No
Unknown
Reporter Name (First and Last)
First Name
Last Name
Reporter Email Address
example@example.com
Attach Supporting File (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Report
Should be Empty: