The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Required format:

Animal Bites Case Report Form

Thank you for reporting an animal exposure to the Rhode Island Department of Health. Please complete the case report form below.

Contact the Center for Acute Infectious Disease Epidemiology at 401-222-2577 or ridoh.infectiousdisease@health.ri.gov with any questions.

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Name of Person Completing Intake:	Date of Intake:
Note: Person completing intake is the person completing this survey.

Nurse Conducting Triage:

* must provide value

Investigator Name:

* must provide value

Investigator Name (if not listed above):

* must provide value

Investigator Email

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Risk Level

* must provide value

Lowest risk Low risk High risk

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DIS Case Specification

4 day callout Expedited Submitted for testing, low risk Pending victims

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Patient Information

Last Name:		First Name:
Date of Birth:	Age:		Current Sex:
Street Address:
City:	State:*		Zip Code:
Phone Number:	Ext:	Phone Type:
Secondary Phone:	Ext:	Secondary Phone Type:
Race (choose all that apply):		Ethnicity:

Additional Contact Name:		Additional Contact Phone:

*If patient is from a country outside the U.S., choose "Other" for State, then choose patient's country of residence below.

Country of Residence:

Incident Information

Incident Date:	Incident City:	Incident State:*
Name of Person Reporting to RIDOH:		Report Date:
Phone Number of Person Reporting to RIDOH:		Ext:
Secondary Phone Number:		Ext:
Organization of Person Reporting to RIDOH:

*If incident occurred in country outside the U.S., choose "Other" for State, then choose country of incident below.

Incident Country:

Exposing Animal:

* must provide value

Dog

Cat

Bat

Raccoon

Skunk

Ferret

Horse

Other

Unknown

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Other Exposing Animal

Other exposing animal, if not listed above

Animal Ownership Status

* must provide value

Owned Stray Unknown

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Is the owner the victim?

* must provide value

Yes No Unknown

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If dog or cat is NOT owned by the victim, please report owner information below:

Last Name:		First Name:
Street Address:
City:	State:		Zip Code:
Phone Number:

Status of animal at time of report:

Status:

* must provide value

Not captured but known to victim

Not captured

Submitted for rabies testing

Quarantined

Unknown

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Check here if you are an ACO

ACO Notes

(Include Rabies Vaccination Status and Final Dispo here)

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Wound Information

Wound Type (choose all that apply):

Wound Location (choose all that apply):

Description of Incident

This should be a brief, 2 sentence description of the incident.

* must provide value

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Final Disposition

*If changing Final Disposition after information below has already been entered, click on the new Final Disposition first, before deselecting the original one.

* must provide value

Alive and Well

Dead but not tested for rabies

Quarantined (location):

Submitted to RI State Health Lab for testing

Not captured

Unknown

On-Call Intake

Other (specify):

Lab Exam of Animal

Is the Rabies Number available?

Are the rabies lab results known?

Date of Lab Result:		Rabies Number:	If bat, species:
Lab Exam Results:

Other Species of Bat

Rabies Vaccination Status of the Animal

Up to Date Not Up to Date Unknown Does Not Apply

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Was the patient treated?

* must provide value

Yes No

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Recommendations for Post Exposure Prophylaxis

Recommendation

*If changing recommendation after information below has already been entered, click on the new recommendation first, before deselecting the original one.

* must provide value

No Risk

Low Risk Exposure

Rabies Exposure

Pending (For DIS Use Only)

*If changing vaccination outcome after patient/vaccine release information has already been entered, click on the new outcome first, before deselecting the original outcome.

Rabies Exposure Vaccination Outcome:

* must provide value

HRIG and 4 doses of vaccine

HRIG and 5 doses of vaccine (patient immunocompromised). Titer required 2 weeks after final dose.

No HRIG and 2 doses of vaccine (patient previously vaccinated with FDA-approved vaccine-HDCV or PCEC).

Off-schedule vaccination - describe:

Other vaccination recommendation - describe:

Patient refused vaccine after risk counseling by nurse and/or MD

Unable to reach patient. No response to letter.

Patient treated out of state.

Date letter sent:

* must provide value

M-D-Y

30 Days After Letter Sent

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Patient Information if Receiving Vaccine

Weight (lbs):		Weight (kgs):
Insurance:		Name of Insurance Plan:
Immunosuppressed:		Specify Condition:
Previously Vaccinated:		If yes, when:
Egg allergy?

Vaccine Release Information

Authorizing RIDOH Physician:
Dispensing Pharmacy:
Place of 1st Dose:
Place of Remaining Doses:
Date of Vaccine Release:
Vaccine Released By:

Month of Vaccine Release

Anticipated Vaccine Schedule
1st Dose (day 0):	2nd Dose (day 3):	3rd Dose (day 7):	4th Dose (day 14):	5th Dose (for immunocompromised individuals, day 28):

Click here if you are ______ staff

Brown University Health

Number of Doses Needed

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Rabies Immune Globulin

RIG Needed?

Dose of RIG (20 units/kg)

Dose of RIG (mL)

Vaccine Schedule *If dose was received elsewhere, leave date blank.
1st Dose (day 0):	2nd Dose (day 3):	3rd Dose (day 7):	4th Dose (day 14):	5th Dose (for immunocompromised individuals, day 28):

Modification to Vaccine Schedule?

Vaccine Outcome Notes

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RIDOH Investigation Details

Staff Notes - Entry #1

Name:		Date:

Staff Notes - Entry #2

Name:		Date:

Staff Notes - Entry #3

Name:		Date:

Staff Notes - Entry #4

Name:		Date:

Staff Notes - Entry #5

Name:		Date:

Staff Notes - Entry #6

Name:		Date:

Staff Notes - Entry #7

Name:		Date:

Staff Notes - Entry #8

Name:		Date:

Staff Notes - Entry #9

Name:		Date:

Staff Notes - Entry #10

Name:		Date:

Investigation Start Date

M-D-Y

4 Day Callout Date

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Expedited Date

View equation

Other Date

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Dispo Due Date

View equation

Dispo Due Date - 2

View equation

MMWR Week

View equation

MMWR Year

View equation

What stage is this case in?

* must provide value

Incomplete

Initial Entry

Assigned Out Not Started

Low Risk In-Progress

High Risk In-Progress

Wildlife Rehab Submissions

RN Consult Needed

Letter Sent-Low-Risk

Letter Sent-High-Risk

Submitted for Testing

Closed Out of State

Closed In State

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Duplicates Request

Check here to request a duplicate of this record.

How many copies do you need?

You just closed an Out of State case as "Closed, In State". Please correct this above.

Incomplete Closures

Check to close as incomplete case.

Name of RIDOH Staff Closing the Case:

Date Case Closed:

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File Upload

File Upload

File Upload

Animal Bites CRF

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