APPENDIX H
ILL/DEAD BIRD REPORT FORM, NEW YORK STATE, Year 2000
See Guidelines for Reporting and Submission of Birds and Mammals, West Nile Virus, for additional instructions on use of this form and reporting system. Please enter data directly into the HIN if possible.
Use this form only under two circumstances:
If not submitting birds for testing, you can use the same form to indicate multiple birds, if all the same species, date found, and location found. If submitting a bird for testing, each bird must be entered on a separate form.
If you are entering the data from this form onto the HIN, immediately after adding the record, a unique identifier will be generated by the HIN. If you are keeping this paper copy of the record, you may wish to write this number here:
NY State ID: ________________________ Local ID: (if a local ID is assigned): ________________________
If you are faxing this form to NYSDOH for data entry until your HIN access is obtained, you should leave the NY State ID number blank when faxing the form, and a number will be generated after NYSDOH enters the form.
If submitting a bird for testing, write the WPU number here: ____________________ This number is pre-assigned by the WPU and is the number on the laminated card that must accompany the bird in shipment.
Date form Completed/Updated: _____________
Dead Bird(s) Found by: Name: _____________________________ Date of initial report: ________________
Type (of person reporting dead bird): DEC____ Local Health_____ Public______ Other_____________________
Day phone: ________________________ Night Phone: _______________________
Address: ___________________________ Email: _____________________________
City: __________________________ State: _________ Zip: ______________
Bird(s) Information: Species: Crow_____ Fish Crow______ Bluejay_____ Other species: _____________ Date found: ______________
Symptoms: Dead, evidence of trauma____ Dead no obvious cause_____ Ill, with neurologic signs________________
Other: _______________________________
Estimate death date: __________ Number of Birds Dead: ______ Ill: _____
Type: Captive_____ Free-ranging______ Maintained: Indoor____ Outdoor_____
Location of Bird(s):
Address: _________________________________ City: _________________ Township: ___________________
State: ___________ Zip: _________________ County/Borough:____________________
Nearest cross street: ___________________________________
If public site, provide name: ________________________________________________
Latitude83: _________________ Longitude83: __________________
If submitting a bird for necropsy and WNV testing, complete the following: Submitted for Necropsy by:
Name: _________________________________ Agency: ___________________________
Day phone: ______________ Night Phone: _______________ Email: _________________________
Address: _________________________ City: ________________ State: _____ Zip: _________
Shipped to: WPU (DEC) __________ Other: __________________________________ (Form Updated 4/4/00)
Revised: May 2000