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Animal Disease Reporting Form for Veterinarians

As of January 1, 2018, amendments to O.Reg. 557 (Communicable Diseases – General) under the Health Protection and Promotion Act came into force, which now require veterinarians and directors of veterinary laboratories to report suspect and confirmed animal cases of the following to their local public health unit.

Avian chlamydiosis
Avian influenza
Novel influenza in mammals (defined as any influenza virus not already known to be endemically circulating in Ontario’s animal species)
Echinococcus multilocularis infection

Reporting Veterinarian Clinic Information

Veterinarian Clinic Name:

First Name (Reporting Contact):

Last Name (Reporting Contact):

Clinic Address:

City:

Postal Code:

Phone Number:

Fax Number:

Email Address:

Disease Reporting Information

Type of animal you are reporting:

The case is:

Suspect case

Confirmed case

Upload associated laboratory test results

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Date of onset of clinical signs in the animal:

Current health status of the animal:

Ill

Not Ill

Recovering

Deceased

Euthanized

Other

Current location of the animal:

Owner's home

Veterinary clinic/office

Other

Animal Owner Contact Information

Owner's First Name:

Owner's Last Name:

Owner's Address:

Owner's City:

Owner's Postal Code:

Owner's Phone Number:

Owner's Email Address:

Personal information contained on this form is collected under the authority of the Health Protection and Promotion Act R.S.O. 1990, cH.7., s.5. This information is collected and used for the purposes of prevention and control of diseases through investigations, conducting risk assessments of suspected exposures and case management. Questions about this collection and use of information should be addressed to Durham Region Health Department, Manager, Health Information, Privacy and Security at 605 Rossland Rd E., P.O. Box 730, Whitby, ON L1N 0B2, (905) 668-7711.

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Animal Disease Reporting Form for Veterinarians

Reporting Veterinarian Clinic Information

Disease Reporting Information

Animal Owner Contact Information