Rabies/Lyssavirus Post-Exposure Prophylaxis Form

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DEPARTMENT OF HEALTH Page 1 of 2

Form ID: HEALTHINTRA-1880-10724

Rabies/Lyssavirus Post-Exposure Prophylaxis Form

Complete this form for ALL cases requiring lyssavirus post-exposure prophylaxis. This includes giving rabies immunoglobulin (HRIG) and/or rabies vaccine.

Notification completed by:………Telephone:………

Reporting State/Territory:………Date PHU notified ___/___/_____

Case Details

Surname………. First Name………... HRN………

Date of Birth __/__/____ Age ……….. Sex: M □ F □

Aboriginal □ Torres Strait Islander □ Aboriginal & Torres Strait Islander □ Non-Indigenous □ Unknown □

Address:……… Post Code………...

Phone Number……….

Email:………

Any known allergies (including eggs) Yes □ No □ – Please specify ……….

Current Medical Conditions - Please specify………...

Current Medication………..

Weight……….kgs

Exposure

Date of exposure:………Time of Exposure:………..

Place of Exposure (Country/State):………

Post Code:………

Type of Animal: Bat □ Dog □ Monkey □ Other □ ………

Type of wound: Bite □ Scratch □ Lick □ Saliva □ Mucous membrane □ Other □………

Was the animal provoked? Yes □ No □

Wound description. Include site and size/depth of wound/s:………

Was the skin broken? Yes □ No □ Did the wound bleed? Yes □ No □

Has the wound been cleaned? Yes □ No □ If yes, how has it been cleaned e.g. soap and water, antiseptic? ...

How did the exposure occur? E.g. picking up a bat...

Did the animal appear unwell? Yes □ No □ If yes, describe behaviour………

Is the animal still alive? Yes □ No □

If the animal is still alive has the animal been submitted to a veterinary laboratory? Yes □ No □ If sent to a laboratory, where has it been sent to?...

Date sent ___/___/______

Results of tests if known ………..

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Rabies/Lyssavirus Post Exposure Prophylaxis Form

DEPARTMENT OF HEALTH Page 2 of 2

Form ID: HEALTHINTRA-1880-10724

Office Use Only:

Net Epi Case ID:

Completion Date:

Rabies Vaccination Information

Pre Exposure Vaccine Course

Has the person ever had a rabies vaccine (including pre exposure vaccine courses)? Yes □ No □ Source of Information: AIR □ CCIS □ Self recall □ Personal Health record □

Please list details in table below

Vaccination History BEFORE exposure Dose Number e.g. 1 &

name of vaccine Date of administration Details – dosage, route

& site of administration Country of administration

Post Exposure Prophylaxis Information

Has the person already had any intervention post exposure e.g. vaccination, HRIG. Yes □ No □ Please list details in table below

Vaccination/Medication history AFTER exposure

Type & name of medication : Vaccine

or HRIG

Dose

number Date of

administration Place & Country of administration

e.g. Indonesia, CDC Darwin, ED Details ( Dosage, Route & site of administration, including infiltration site)

Any adverse event from vaccination? Yes □ No □

If Yes: Has an Adverse Event Following Immunisation form been completed? Yes □ No □

Has the person received a Tetanus vaccine Yes □ No □ Date Administered ……….

Further Management Required

HRIG required Yes □ No □

Dose = weight in Kg / 20IU = ………..ml Dose ordered ……..IU = ……..mls Date Ordered: ………

Further vaccination required? Yes □ No □ Number of further vaccine doses required………..

Other Comments:………..

………...

Please send completed forms to CDC Darwin by Fax: 08 8922 8310 or Email [email protected]

Dose Number Date Required Date administered Place of administration