Novel Animal Illness Notification Report

IMMEDIATELY submit this report to Huron Perth Public Health.
For URGENT consultations regarding a novel animal illness phone the health unit.
During office hours: 1-888-221-2133. After hours, weekends and holidays: 519-482-7077 (Huron County) or 1-800-431-2054 (Perth County).

A) Report/Intake

Date Reported:

Person Reporting:

Agency Name:

Phone:

B) Animal Information

Animal Name:

Sex of animal:

Female:

Male:

Animal species:

Dog

Cat

Bird

Other

Define other:

Breed:

Colour:

Markings:

Age:

Description:

Animal's permanent address:

911 or Street Number:

Street:

City/Town:

Postal Code:

Animal's current location (if different):

911 or Street Number:

Street:

City/Town:

Postal Code:

C) Notification of Animal Illness

Please identify suspect and/or confirmed animal illness:

Suspect and/or confirmed cases of avian chlamydiosis

Suspect and/or confirmed cases of avian influenza

Suspect and/or confirmed cases of Echinococcus multilocularis infection

Suspect and/or confirmed cases of Psittacosis

Suspect and/or confirmed cases of novel influenza in mammals (defined as any influenza virus not already known to be endemically circulating in Ontario's animal species)

Other

Define other:

D) Incident Details

Date of incident:

Status of case:

Confirmed case:

Suspect case:

Lab results attached:

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Symptoms:

Animal's current health status:

Number of people exposed:

Names of people exposed:

E) Animal Owner Information (or person with custody of animal)

Owner's Name:

Home phone:

Other phone:

Owner's permanent address:

911 or Street Number:

Street:

City/Town:

Postal Code:

This personal information is collected under the authority of the Health and Protection and Promotion Act (1990) Reg. 557 Sec. 2. It will be used to conduct investigations and for the purposes of monitoring and surveillance. For further details concerning this collection, contact the Privacy Officer at the Huron Perth Public Health, 777228B London Road, RR 5, Clinton, ON N0M 1L0 or call 519.482.3416 or 1.877.837.6143 or e-mail healthprivacy@hpph.ca

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Novel Animal Illness Notification Report

A) Report/Intake

B) Animal Information

Animal's permanent address:

Animal's current location (if different):

C) Notification of Animal Illness

D) Incident Details

E) Animal Owner Information (or person with custody of animal)

Owner's permanent address: