animal incident report - scdhec
TRANSCRIPT
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DHEC 1799 (06/2020)
SCDHEC, UST Management Division, 2600 Bull Street, Columbia, SC 29201, PHONE (803)898-7957 FAX (803) 896-6245 www.scdhec.govSOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Animal Incident ReportBureau of Environmental Health Services
County Where Incident Occurred: DHEC Use OnlyIncident Date: Incident Time: c AM c PM ABRIS #:Reported By: Phone: Date Received:Address/Location of Incident: (Same as Victim c)Incident Circumstances:
Current Date: Current Time: c AM c PMAttending Physician: Phone: Fax:Hospital/Clinic:
c Human Sex: c M c F c Animal DOB: Age:Name: Guardian/Owner (If Minor/Pet):Address (If Not a Street Address, Give Directions):City: State: Zip:Phone: Alternate Phone:Email:Wound Location and Severity:
Signature:
Type of Animal: Breed: Size/Color:Owned: c Yes c No Animal's Name: Sex:
Owner's Name: (Same as Victim c)Address (If Not a Street Address, Give Directions):City: State: Zip:Phone: Alternate Phone:Email:Current Location and Health Status of Animal:
Rabies Vaccination InformationDate of Vaccination: c 1 yr c 3 yr Tag #:Veterinarian:
Incident Information
Hospital/Clinic Information
Victim Information
Offending Animal Information
** Providing correct and accurate information will allow us to properly conduct the rabies investigation.**Personal information provided on this document is subject to public scrutiny or release.
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Please note: Your contact information may be shared with animal control officers, physicians, veterinarians, law enforcement officers, and others as needed to conduct the investigations.
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County of Occurrence Main Office Phone Fax Email
Aiken Barnwell Edgefield
Saluda
Aiken (803) 642‐1637 (803) 643‐4027 [email protected]
Anderson Anderson (864) 260-5569 (864) 222-3923 [email protected]
Beaufort Colleton
Hampton Jasper
Beaufort (843) 846-1030 (843) 846-0604 [email protected]
Berkeley Charleston Dorchester
Charleston (843) 953‐0150 (843) 202‐7050 [email protected]
Fairfield Lexington Newberry Richland
Columbia (803) 896‐0620 (803) 896‐0617 [email protected]
Chesterfield Darlington
Dillon Florence Marion
Marlboro
Florence (843) 661‐4825 (843) 661‐4858 [email protected]
Greenville Pickens
Greenville (864) 372‐3273 (864) 282‐4371 [email protected]
Abbeville Laurens
McCormick Greenwood
Greenwood (864) 227‐5915 (864) 942‐3680 [email protected]
Horry Georgetown Williamsburg
Horry (843) 915‐8801 (843) 915‐6503 [email protected]
Chester Lancaster
Lancaster (803) 285-7461 (803) 285-5594 [email protected]
Allendale Bamberg Calhoun
Orangeburg
Orangeburg (803) 533‐5490 (803) 268‐5784 [email protected]
Cherokee Union
Spartanburg Spartanburg (864) 596‐3327 (864) 596‐3920 [email protected]
Clarendon Kershaw
Lee Sumter
Sumter (803) 778‐6548 (803) 934-2938 [email protected]
Oconee Walhalla (864) 638-4185 (864) 638-4186 [email protected]
York York (803) 909-7377 (803) 909-7538 [email protected]
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Form Title: DHEC 1799 Animal Incident Report
Form Purpose: Used to investigate and collect information about animal bite incidents.
Information includes incident information, hospital/clinic information, victim information, and
offending animal information.
Audience: Health Care Provider/Facility
Submitting Instructions: Please fax or email the completed animal incident report to the
appropriate Environmental Health Services’ regional office by the end of the next working day.
DHEC Record Retention Schedule: Negative Rabies Lab Test Result – Retain record for three
years after investigation is closed, destroy record. Positive Rabies Lab Test Result – Retain
record for five years after investigation is closed, destroy record.
DHEC 1799 (06/2020) 3