MA SPHL Use Only - DO NOT WRITE HERE

Specimen Request Form for Rabies Testing
MA State Public Health Laboratory
305 South Street 
Jamaica Plain, MA 02130-3597
Tel. 617-983-6385

•	All animals must be euthanized prior to submission. For most specimens, submit only the entire head. 
•	Bats should be submitted whole, without removing the head. 
•	For large animals or those undergoing other diagnostic procedures, submission of the cerebellum and a complete cross-section of the brainstem is permissible. 
•	Failure to submit an acceptable specimen will result in an unsatisfactory specimen and no test result. 
•	Specimens must be properly packaged to prevent leakage of contents and transported the same day or shipped overnight ONLY to maintain specimen quality.  Complete packaging and shipping instructions available at: www.mass.gov/dph/rabies

Fully complete Sections 1-5: 
	
1.  PERSON COMPLETING THE FORM AND SENDING IN THE ANIMAL FOR TESTING  This person will be contacted with the result. For negative results, this person will be  responsible for contacting any individual who needs to be made aware of the negative test result.	2.    PERSON WHO FOUND ANIMAL OR ANIMAL OWNER                                            	
Name: 	Name:   	
Address: 	Address: 	
City/Town:                        State:             Zip code:	City/Town:                   State:                    Zip code:	
Phone number: (           ) 	Phone number: (           )	
3.  INFORMATION ON THE ANIMAL BEING TESTED	

________________
Species

____/_____/______
Death date	Reason for rabies testing:
•	Human exposure
•	Pet exposure
•	Acting sick
Vaccination History
•	Rabies vaccinated (__/__/__)
•	Not rabies vaccinated (not current)
•	Unknown
	Location where animal was found:
Street: _______________________

City/Town & State:  _______________      _____
	Cause of Death:

•	Natural Causes
•	Euthanasia  (Specify method:  _______________________

	Euthanized			   	Eutha	
4.  INFORMATION ON PERSON EXPOSED BY ANIMAL BEING TESTED If the animal submitted tests positive for rabies, this person will be contacted directly by MDPH.	5.  INFORMATION ON ANIMAL EXPOSED BY ANIMAL BEING TESTED   If the animal submitted tests positive for rabies, the owner listed will be contacted directly.  	

•	Exposure date:   
 
        ____/____/______  	
•	Bite
•	Scratch
•	Other_______	Exposure date:   ____/____/_______	
		Name of Animal or Description:                                                          	Species:	
Name                                             	Name of Owner:	
Address: 	Address:                                        	
City/Town                               State                         Zip Code	City/Town                             State                           Zip Code	
Phone Number:   (        )	Phone Number:   (        )	
•	Multiple human exposures (include on reverse side)	•	Multiple animal exposures (include on reverse side)	
6.  - DO NOT WRITE HERE-
Specimen Accession Number: 	____________________	  Date Specimen Received:     _____/______/_____________

Date Tested:   _____/______/________	  Test Results:	 Positive (rabid)     Negative (not rabid)    Unsatisfactory                                                                                            

Date Result Generated: _____/______/_______	 Person Interpreting the Result: _______________________________
	
Date Notified: ____/_____/______     Person/Agency Notified: _________________________________________________            

Notified by: __________________   Spoke with person     Left message     Comments:  __________________________