Domestic Animal Exposure · Custom Portal

Domestic Animal Exposure Report

Report a new event that involves a potential rabies exposure to a domestic animal (a pet or livestock).

A potential rabies exposure includes, but is not limited to, any physical contact or any unsupervised time between a domestic animal and a high-risk rabies vector. High-risk vectors include but are not limited to: bats, raccoons, foxes, skunks, groundhogs, opossum, coyote.

By law, any person with knowledge of a domestic animal potentially exposed to rabies should immediately notify their local Health Department. Submitting a completed form meets that requirement.

If you have any questions, please contact the Fairfax County Health Department Rabies Program at 703-246-2433.

Reporter Information

Incident Type

Please select where you are reporting from:

Name of Reporting Facility

Patient Visit Date & Time

Name of person reporting exposure

Phone number of person reporting exposure

Biting/Exposing Animal Details (please provide details on the animal that exposed your pet)

Is the animal confined at the reporting facility?

Species

Specify

Location where biting/exposing animal was last seen:

Provide any additional notes about the biting/exposing animal, including odd behavior observed

Exposed Animal Details

Species

Breed

Pet Name

License Number

Has the pet ever been vaccinated against rabies before?

Rabies Vaccine Expiration Date

Owner First Name

Owner Last Name

Owner Home Street Address

City

State

Zip Code

Phone Number

Alternate Phone Number

Email Address

Incident Details

Date of Exposure

Was the pet injured by the high-risk vector?

Description of incident

Did the pet have direct physical contact with the high-risk vector?

Was the pet left alone unsupervised in the same area as the high-risk vector?

Did any other household pets have direct physical contact and/or were in the same area as the high-risk vector?

Did the owner report any neighbor pets seen near the high-risk vector?

Is the high-risk vector available for testing?

Is the high-risk vector dead or trapped on the victim's property?

Did the event occur at the home address listed above?

NoYes

Do you know exact address when incident happened?

NoYes

Street address where event occurred

City

State

Zip code

Please provide any additional notes about incident

Rabies Administration

Last Name of Investigator

AC Case Number

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