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

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

64U6n2NnJp4JbpI54KrSYnubbL8ps2PQreTZuRqMAhq3YzXsXBFi4KW

Animal Encounter Intake Form

Arkansas law requires that animal bites be immediately reported to the Arkansas Department of Health.

Rabies is a disease transmitted from animal to humans, which is caused by a virus. It is important to take steps to thoroughly investigate animal bites so timely care can be provided to protect people from the disease.

Please, fill out the survey below. Someone will investigate your case. For more information you can click on this link: Rabies Arkansas Department of Health .

For submitting an animal for rabies testing you can click on this link: Animal Rabies Submission Form (arkansas.gov)

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

Remember to open new investigations as a survey before entering data for the first time

Date of Report

* must provide value

M-D-Y

I am:

* must provide value

Self reporting

Someone reporting on behalf of another person

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Association with person you are reporting on behalf of:

* must provide value

Physician/Physician Office

Animal Control/Law Enforcement

Veterinarian/Vet Clinic

Parent/Guardian

Environmental Health Specialist/County Health Unit

Other Relation

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Were you bitten by an animal?

* must provide value

Yes

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Was a person bitten by an animal?

* must provide value

Yes

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Was a pet bitten by another animal?

* must provide value

Yes

Unknown

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Is the biting animal wild or domestic?

Wild

Domestic

Unknown

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Is the biting animal a pet?

Yes

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COUNTY where animal encounter occurred?

* must provide value

Public Health Region of County where Animal Encounter Occurred

View equation

Facility or Business Name

* must provide value

Facility or Business Fax

First Name

* must provide value

Last Name

* must provide value

Phone Type

Phone Number

Please, enter a phone number or email. Not providing contact information will delay the investigation.

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Date of Birth

* must provide value

M-D-Y

Age

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Birth Sex

Male

Female

Unknown

Decline to Answer

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Race (select all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Unknown

Decline to Answer

Ethnicity

Not Hispanic or Latino

Hispanic or Latino

Unknown

Decline to Answer

reset

Address

Address 2

City

* must provide value

State

Zip Code

* must provide value

County

Public Health Region

View equation

Please, upload any relevant documentation here.

Upload file

Mark field as:

[Clear value]

Asked but unknown (ASKU)

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.