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Animal Exposure Report

Your Environment / Rabies / Animal Exposure Report

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Grey Bruce Health Unit Animal Exposure Report

The information collected will be forwarded to a public health inspector for follow-up. This investigation is mandatory under the Health
Protection & Promotion Act. Contact the municipality to determine any enforcement under local bylaws or Dog Owners’ Liability Act. For
more information on animal exposure investigations please visit our website at: https://www.publichealthgreybruce.on.ca.

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Incident Information
Date of Incident
Month - Day - Year
Reported by
Details of Incident
Date Reported
Month - Day - Year
Save & Resume Later

Patient Information
Patient’s Name
Parent or Guardian
Gender
MaleFemaleOther
Birth Date
Month - Day - Year

Patient Permanent Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Does patient have a temporary address?
YesNo
Temporary Address Start Date
Month - Day - Year
Temporary Address End Date
Month - Day - Year

Patient Temporary Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Home Phone
Phone Number
Cell Phone
Phone Number
Email
Type of Exposure: (check all that apply)
BiteScratchBatMucous Membrane
Skin Broken
YesNo
PATIENT WEIGHT
Measurement
Anatomical Location of Wound
Where Treated
Treated By
Save & Resume Later

Animal Owner (or person with custody of animal)
Owner information is same as patient
YesNo
Owner's Name
Gender
MaleFemaleOther

Owner's Permanent Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Owner's Temporary Address (if applicable)

Street Address
Street Address 2
City	Region
Postal Code	Country

Temporary Address Start Date
Month - Day - Year
Temporary Address End Date
Month - Day - Year
Home Phone
Phone Number
Cell Phone
Phone Number
Email
Save & Resume Later

Animal Information
Species
Name
Breed
Colour
Size/Weight
Age
Gender
MaleFemaleUnknown
Animal is ... (check all that apply)
DomesticOutdoorStray
IndoorWild
Animal Vaccinated for Rabies
YesNoUnknown
Date Vaccinated
Month - Day - Year
Tag #
Veterinarian
Address
Phone
Phone Number
Provoked (ie. any circumstances during which a person touched, threatened, scared, fed, or otherwise interacted with the animal prior to the incident)
YesNo
Other Animals
YesNo
Other Animals Vaccinated
YesNo

This information is being collected pursuant to the Health Protection and Promotion Act, R.S.O. 1990, c.H.7 and will be retained, used, disclosed and disposed of in accordance

with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c.M.56, the Personal Health Information Protection Act, 2004, S.O.c.3 and all applicable

federal and provincial legislation and regulations governing the collection, retention, use disclosure and disposal of information. Any questions regarding this collection may be

directed to the Director of Corporate Services at 101 17th Street East Owen Sound, N4K 0A5, (519) 376-9420.

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Owen Sound
101 17th Street East
Owen Sound, ON, N4K 0A5
519-376-9420 or 1-800-263-3456
Business Hours: 8:30am to 4:30pm - Monday to Friday

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