OHHABS Animal Form

One Health Harmful Algal Bloom System (OHHABS) Animal Form
Form Approved
OMB No. 0920-1105
Exp. Date: 11/30/2025

One Health Harmful Algal Bloom System (OHHABS)

Animal Form

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection
Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1105). DO NOT MAIL FORMS TO THIS ADDRESS

CDC REPORT ID

CDC FORM ID

STATE REPORT ID

REPORT DATE CREATED

**Note: Create or update a report by appending an environmental form to this animal form.If reporting more than one animal, please create one report for each animal unless they are part of a large herd, flock, school of
fish, etc.

GENERAL INFORMATION – Group Reports should include only 1 species type. If multiple species are reported please complete separate group
report forms
Does this illness report describe a single animal or a group of animals?
☐Single animal
☐Group of animals (e.g., flock of birds)
ANIMAL DESCRIPTION
What is the category of animal(s) being reported?
☐Domestic Pet ☐Livestock ☐Wildlife
What type of animal are you reporting?:__________
Animal Common Name?(e.g.,dog breed, fish species,etc.)__________
[Single Animal] What is the weight of the animal?__________(lbs) ☐Unknown
[Domestic Pet] How old is the animal?__________(years) ☐Unknown
[Livestock or Wildlife] What is the maturity of the animal/s?
☐Juvenile ☐Adult ☐Both Juvenile and Adult ☐Unknown

ANIMAL EXPOSURE INFORMATION
Date of Discovery(MM/DD/YYYY):__________
Did the animal(s) have exposure to algae, cyanobacteria, or their toxins on a single date or multiple dates? (Select one)
☐Single date
Date of exposure(MM/DD/YYYY):__________
☐Multiple dates
Date of first exposure(MM/DD/YYYY):__________
Date of last exposure(MM/DD/YYYY):__________
☐Unknown
If reporting a single animal:
Did the animal die?
☐Yes ☐No ☐Unknown
[If yes] Date of death(MM/DD/YYYY):__________ ☐Unknown
[If yes] In what condition was the animal found? (Select all that apply)
☐Fresh
☐Stranded
☐Scavenged
☐Unknown
☐Decomposed
If reporting a group of animals:
How many animals were affected? __________ ☐ Number is an estimate
Did any of the animals die?
☐Yes ☐No ☐Unknown
[If yes] How many animals died?__________ ☐ Number is an estimate
[If yes] Date of deaths (MM/DD/YYYY):____________ ☐Approximation ☐Unknown
[If yes] Was this event considered a mass die-off? ☐Yes ☐No ☐Unknown
[If yes] In what condition were they found? (Select all that apply)
☐Fresh
☐Stranded
☐Scavenged
☐Unknown
☐Decomposed
Is the setting of the exposure the same as the HAB event reported?
☐Yes ☐No ☐Unknown
How did exposure occur? (Select all that apply)
☐Inhalation (e.g. walking near water)
☐Other (specify):__________
☐Direct Contact (e.g. swimming/playing/walking in water)
☐Unknown
☐Ingestion (e.g. algal mat, drinking water)

SIGNS OF ANIMAL ILLNESS
Date of illness onset(MM/DD/YYYY):__________ ☐Unkonwn
Approximate time of illness onset:
☐ Early morning (12:00AM – 6:00AM)
☐ Morning (6:00AM – 12:00 PM)
☐ Afternoon (12:00PM – 6:00PM)
Date of illness recovery (MM/DD/YYYY):__________ ☐Unknown
Approximate time of illness recovery:
☐ Early morning (12:00AM – 6:00AM)
☐ Morning (6:00AM – 12:00 PM)
☐ Afternoon (12:00PM – 6:00PM)
Time of illness onset after exposure:
☐ ≤3 hours ☐ >3 ≤ 12 hours ☐ >12 ≤ 24 hours ☐ >24 ≤48 hours
Commonly Reported Signs
Vomiting
Diarrhea
Lethargy
Ataxia (stumbling, loss of balance)
Anorexia (loss of appetite)
Seizure/Convulsions
Weakness
Other signs of illness (Select all that apply): __________
Did any signs of illness reoccur after multiple exposures?
☐Yes ☐No ☐Unknown

☐ Evening (6:00PM – 9:00PM)
☐ Night (9:00PM – 12:00AM
☐Unknown
☐ Evening (6:00PM – 9:00PM)
☐ Night (9:00PM – 12:00AM
☐Unknown
☐>48 hours

☐Unknown

Yes/No/Unknown
☐Yes ☐No ☐Unknown
☐Yes ☐No ☐Unknown
☐Yes ☐No ☐Unknown
☐Yes ☐No ☐Unknown
☐Yes ☐No ☐Unknown
☐Yes ☐No ☐Unknown
☐Yes ☐No ☐Unknown

MEDICAL INFORMATION
Did the animals(s) receive any veterinary medical care or treatment?
☐Yes ☐No ☐Unknown
[If yes] [Group of Animals] How many received veterinary care or treatment? __________
At the time of exposure was the animal(s) considered immunocompromised?
☐Yes ☐No ☐Unknown
At the time of exposure did the animal(s) have a chronic disease?
☐Yes ☐No ☐Unknown
[If yes] Specify chronic disease: __________
ANIMAL LABORATORY TESTING
Were clinical specimens tested?
☐Yes ☐No ☐Unknown
[If yes] What type(s) of clinical testing were done to diagnose the illness or rule out other causes? (Select all that apply)
☐Imaging (e.g., x-ray, ultrasound, etc.)
☐Bloodwork
☐None
☐Fecal analysis
☐Other (specify) __________
☐Toxicological Analysis
☐Unknown
☐Urinalysis
ANIMAL TESTING RESULTS
In the table below, please report any laboratory results of clinical specimens that were tested for algal/cyanobacterial toxins or species—more
extensive results may be attached to this report)
Clinical Specimen Number
1
2
3
Result Detected?
Specimen Collection Date
(MM/DD/YYYY)
Specimen Type
(e.g., Blood)
Classification
(e.g., Cyanobacteria)
Genus or toxin
(e.g., Microcystis)
Species
(e.g., aeruginosa)

Concentration
(e.g., 20)
Unit
(e.g., ppm)
Test type
(e.g., ELISA)
ANIMAL TESTING RESULTS REMARKS (Remarks should NOT include PII, CCI, other identifiers, webpage links, or additional location information.
Remarks should ONLY include information about the sample, test results, if whole blood what color tube top, or other relevant laboratory
information.):_____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
GENERAL REMARKS (Remarks should NOT include any PII, CCI, other identifiers, webpage links, or lab/sample/testing information. Remarks should
only include relevant information not captured in the form.):__________________________________________________________________
________________________________________________________________________________________________________________________