Animal Incident Report - SCDHEC
Transcript of Animal Incident Report - SCDHEC
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.
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]
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.
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