Disease Reporting Form

According to Sec 32. 7 M.R.S.A. §1801 and 01-001 Chapter 206: Prevention and Control of Certain Diseases of Domestic Animals and Poultry, diseases or pathogens must be reported to the Maine Department of Agriculture, Division of Animal Health and Industry. Please fill in all applicable fields below and be sure to hit the submit button when finished.

Contact Information

Date of Report (mm/dd/yyyy):
Reporting Person/Veterinarian's Name:
License Number:
Clinic/Hospital Name:
Contact Email:
Reporting Person/Vet's Phone:
Reporting Person/Vet's Fax:
Disease, pathogen or syndrome name:
Check one:	Confirmed Suspicion
Location of Animals
Street Address:
Town:
State:
Zip:
County:
Premises ID (if known):
Owner's Name and Address
Owner's Name :
Owner's Phone :
Street:
Town:
State:
Zip:
County:
E-mail:
Please fill in the following information (if applicable):
Onset Date:
Species:
Number affected/dead:
Age(s):
Gender(s):
Actions taken prior to notification of the Division of animal Health and Industry? (i.e., diagnosis tests/results, etc.)
Name of laboratory used for initial testing:
Name of laboratory used where diagnosis was confirmed:
Other comments or questions you may have:

If you are unable to submit this form for any reason, please download the printable PDF file, fill that in and fax to 207-624-5044, or e-mail katherine.hayford@maine.gov, or telephone your report by calling 207-287-3701.

Animal Health & Industry

Disease Reporting Form