OHEP Disease Reporting Form

OHEP Disease Reporting Form

County of San Diego - Epidemiology and Immunization Services Branch

Please complete the form below to voluntarily report a single case of another disease, condition or syndrome in animals to the One Health Epidemiology Program (OHEP).

Reporting Veterinarian or Other Contact

Name

Please include first and last name.

Job Title

Animal Hospital or Facility Name

Phone Number

Phone

Animal Information

Species

Select or enter value

If you selected "Other", please specify the species below.

Please enter "N/A" if not applicable.

Animal Name or Identifier

Identifiers can include the animal's tag # or microchip #. Please provide a description of the animal if there is no name or other identifiers (ex: black cat with white paws).

Breed

Sex

Select or enter value

Age

Medical Record Number (Optional)

Animal History

Disease or Syndrome (Clinical Signs) being Reported

Date of Onset

Date of Presentation

Treatment

Brief History and Clinical Presentation

Please include vaccine information if applicable.

Upload Lab Results

Drag and drop files here or

Date of Death

Only enter a date if applicable.

Animal Owner (Optional)

Name(s)

Please include first and last name(s).

Zip Code

Phone Number

Phone

Is it okay for Public Health to contact the owner(s) directly?

Select or enter value

Animal Location (Optional)

Please complete this section if the animal location is different from the owner location.

Animal Hospital or Facility Name

Please specify where the animal is located.

Zip Code

Phone Number

Phone

Thank you for your time!

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