Animal Illness Reporting Form

Please use this form to report an animal illness or death that you think was related to exposure to blue-green algae. If you have questions about this form, please call KDHE - Bureau of Epidemiology and Public Health Informatics at 877-427-7317 or email epihotline@kdheks.gov. Thank you for reporting this incident to us. We are working hard to improve the health of all Kansas residents and visitors.

Please enter today's date.
mm/dd/yyyy:

Please enter the name and address of the person completing the form.
Name:
Street Address:
City:
State:
Zip:
Contact phone number:
Email address:

Please select citizen type that describes you best.
Citizen
Healthcare Provider
State Agency
County Agency
Poison Control Center
Biologist
Veterinarian
Other: 

Please enter the name and contact information of the owner of the animal that became ill or expired if known.
Name:
Street Address:
City:
State:
Zip:
Home or cell phone:

Please provide the age of the animal that was exposed.
Age:

What is the sex of the animal exposed?
Male
Female

Please select which category best describes the animal exposed?
Canine (Dog/Puppy)
Bird
Wild Animal
Feline (Cat/Kitten)
Cow
Horse
Other: 

Where did the exposure occur?
Names of lake or river:
Location on the lake or river:
Town, city or park:
County:

Date of Exposure.
 

Time of exposure.
 

What was the animal doing at the time of exposure?

What was the means of exposure?
Inhalation
Dermal contact
Ingestion
exposure to aerosols
Not sure

Please use the checkboxes below to indicate the areas in contact with water.
Do Not Know
Head
Paws
Legs
Neck
Trunk
Other

Did you notice any dead or sick fish or animals in or near the water?
Yes
No

If yes, please describe the dead or sick animals or fish.

Did you notice any unusual smells or odors.
Yes
No

If yes, please describe the odors.
Do Not Know
Earthy/Moldy
Septic/Sulphur
Fishy/Aquarium
Decayed fish
Medicinal/Phenolic/Alcohol
Crude oil/Petroleum
Other 

Please describe the color and clarity of the water.

Do you remember seeing algae mats or a paint-like film on the water?
Yes
No

What symptoms did the affected animal experience?

How long after the exposure did the symptoms begin?

For each symptom listed above, please indicate how long the symptoms persisted. For example, neurologic-2 days, rash-5 days, etc.

Did the animal see a veterinarian regarding this illness?
Yes
No

If yes, what treatment did the animal receive?

Any additional information or comments:




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