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 RabiesAiken@dhec.sc.gov

Anderson Anderson (864) 260-5569 (864) 222-3923 RabiesAnderson@dhec.sc.gov

Beaufort Colleton

Hampton Jasper

Beaufort (843) 846-1030 (843) 846-0604 RabiesBeaufort@dhec.sc.gov

Berkeley Charleston Dorchester

Charleston (843) 953‐0150 (843) 202‐7050 RabiesCharleston@dhec.sc.gov

Fairfield Lexington Newberry Richland

Columbia (803) 896‐0620 (803) 896‐0617 RabiesColumbia@dhec.sc.gov

Chesterfield Darlington

Dillon Florence Marion

Marlboro

Florence (843) 661‐4825 (843) 661‐4858 RabiesFlorence@dhec.sc.gov

Greenville Pickens

Greenville (864) 372‐3273 (864) 282‐4371 RabiesGreenville@dhec.sc.gov

Abbeville Laurens

McCormick Greenwood

Greenwood (864) 227‐5915 (864) 942‐3680 RabiesGreenwood@dhec.sc.gov

Horry Georgetown Williamsburg

Horry (843) 915‐8801 (843) 915‐6503 RabiesHorry@dhec.sc.gov

Chester Lancaster

Lancaster (803) 285-7461 (803) 285-5594 RabiesLancaster@dhec.sc.gov

Allendale Bamberg Calhoun

Orangeburg

Orangeburg (803) 533‐5490 (803) 268‐5784 RabiesOrangeburg@dhec.sc.gov

Cherokee Union

Spartanburg Spartanburg (864) 596‐3327 (864) 596‐3920 RabiesSpartanburg@dhec.sc.gov

Clarendon Kershaw

Lee Sumter

Sumter (803) 778‐6548 (803) 934-2938 RabiesSumter@dhec.sc.gov

Oconee Walhalla (864) 638-4185 (864) 638-4186 RabiesAnderson@dhec.sc.gov

York York (803) 909-7377 (803) 909-7538 RabiesYork@dhec.sc.gov

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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