Reportable Disease Case Report Form
Colorado Department of Agriculture - Animal Health Division
305 Interlocken Parkway, Broomfield, CO 80021-3484

Phone: (303)869-9130
Fax: (303)466-8515
Hours: Mon-Fri 8am - 5pm

***** After hours: Phone message will indicate staff veterinarian on call *****

Email address *
Reporting Date *
MM
/
DD
/
YYYY
Veterinarian Name *
Your answer
Veterinary Clinic
Your answer
Veterinarian Phone *
Your answer
Veterinarian Email *
Your answer
Animal Owner Name *
Your answer
Owner Phone *
Your answer
Owner Address *
street address, city, state, zip
Your answer
Owner Email
Your answer
Species *
Your answer
Breed *
Your answer
Age *
Your answer
Sex *
Animal Purpose
Your answer
Animal Name
if applicable
Your answer
Official ID *
enter N/A if no official ID
Your answer
Animal Address *
if different than owner
Your answer
County where animal resides *
Your answer
Clinical diagnosis or suspected condition *
Your answer
Date of onset *
MM
/
DD
/
YYYY
Clinical signs *
Your answer
History *
Your answer
Treatment Initiated?
If yes, summarize treatment:
Your answer
Animal Status: *
Number (and species) of animals affected
Your answer
Other animals on premises
Your answer
Tests requested *
Your answer
Date submitted *
MM
/
DD
/
YYYY
Laboratory *
Your answer
Submit
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