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Animal Exposure Reporting Form - Health Care Provider

Information & Instructions

This tool is meant to report animal-to-human exposures only.
Please have details available of any post-exposure prophylaxis administered.
Personal information on this form is collected under the authority of the Health Protection and Promotion Act R.S.O. 1990, C.H.7 for the purposes of an investigation and reporting into rabies exposure. Questions about this collection can be addressed to rabiesinfo@ottawa.ca or 613-580-6744.

For more information on Rabies for Healthcare Providers, please visit our website

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Name of reporting health care professional

First Name:

Last Name:

Street Address:

City:

Province:

Postal Code:

Organization:

Primary Phone Number:

Patient Information

First Name:

Last Name:

Date of Birth:

If the person exposed is under 18, please provide parent / guardian name.

First Name of Parent / Guardian:

Last Name of Parent / Guardian:

Street Address:

City:

Province:

Postal Code:

Primary Phone Number:

Alternate Phone Number:

Is the patient the animal owner / caretaker?

Yes

Unknown

If you need OPH assistance with risk assessments and, if required, to request Rabies Post Exposure Prophylaxis (RPEP), call 613-580-6744 and press 2 to be prioritized as a health care professional. Outside of business hours Ottawa Public Health can be reached by calling 3-1-1.

Has this patient received prepositioned Rabies Post Exposure Prophylaxis (RPEP) in an Ottawa hospital? N.B. If post exposure prophylaxis was given, clinical information, including lot numbers, will be required.

Yes

Known information re: bite or scratch, type of animal, if bitten in another country, location of bite on body, wound care or procedures needed, etc.

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Animal Exposure Reporting Form - Health Care Provider

Information & Instructions

Name of reporting health care professional

Patient Information

How Do I...?

Reporting something to Ottawa Public Health or returning a message

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