The Department of Defense Form 2341, also known as the Continuity of Operations Plan (COOP) Form, is a document used by the United States military to ensure the continuity of government operations in the event of a national emergency. This form is designed to help military officials plan and coordinate necessary actions in order to maintain essential government functions during a crisis. The COOP Form is updated regularly to reflect changes in government operations and areas of potential vulnerability.
| Question | Answer |
|---|---|
| Form Name | Dd Form 2341 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | OCT, dd form 2341 fillable, YYYYMMDD, III |
REPORT OF ANIMAL BITE - POTENTIAL RABIES EXPOSURE
(Please read Privacy Act Statement before completing this form.)
SEQUENCE NUMBER
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Section 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8013, Secretary of the Air Force; DoD Directive 6400.4, DoD Veterinary Services Program; AR
PRINCIPAL PURPOSE(S): Used by medical authorities to record the history, examination, and treatment of a person who has possibly been exposed to rabies; and to record the
ROUTINE USE(S): The DoD "Blanket Routine Uses" that appear at the beginning of the Army's compilation of systems of records apply to this system. Information may be disclosed to aid in preventive health and communicable disease control programs and report medical conditions to Federal, state and local agencies, required by law.
DISCLOSURE: Voluntary. However, failure to provide all the requested information may result in the improper treatment and care being administered to the patient.
1.FROM (Medical Treatment Facility)
2.THRU (Veterinary Service Activity)
3.TO (Chief, Preventive Medicine)
PART I - ANIMAL BITE HISTORY (To be completed by Emergency Room or Primary Care Interviewer)
4. DESCRIPTION OF ANIMAL
5. TIME OF ATTACK
a.TYPE (Dog, cat, etc.)
b. BREED
c. SIZE
d. COLOR
e. SEX
a.DATE (YYYYMMDD)
b. HOUR
6. PRESENT LOCATION OF ANIMAL OR GEOGRAPHIC ADDRESS WHERE ATTACKED
ON POST
OFF POST
7.CIRCUMSTANCES LEADING TO BITE/SCRATCH INCIDENT
8.APPARENT HEALTH OF ANIMAL (Unusual Behavior)
9.ANIMAL OWNER
a. NAME (Last, First, Middle Initial) |
b. STATUS (X one) |
c. PHONE NUMBER |
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MILITARY |
(Include Area Code) |
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CIVILIAN |
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10. RABIES VACCINATION |
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a. VACCINATION STATUS OF ANIMAL |
b. YEAR ANIMAL |
c. TYPE VACCINE |
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VACCINATED |
(If known) |
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d.ADDRESS (Street, City, State, Zip Code)
11. FORM PREPARED BY
a. NAME (Last, First, Middle Initial) |
b. TITLE |
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c. SIGNATURE |
d. DEPARTMENT/SERVICE/CLINIC |
e. DATE PREPARED |
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(YYYYMMDD) |
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12.PATIENT'S IDENTIFICATION (ID impression, if available.) (For typed or written entries give name (Last, First, Middle Initial); pay grade; SSN; unit; duty and home telephone numbers; date; hospital or medical facility.)
DD FORM 2341, OCT 2007 |
PREVIOUS EDITION IS OBSOLETE. |
Page 1 of 3 Pages |
Adobe Professional 8.0
PART II - MANAGEMENT OF ANIMAL BITE CASE (To be completed by Medical Officer (Information from SF 600))
13. DESCRIPTION OF INJURY AND LOCATION ON THE BODY
14. DIAGNOSIS (Injury) (X as applicable) |
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15. RABIES RISK ESTIMATE (X one) |
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ANIMAL BITE |
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CLAW WOUND |
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OTHER |
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MINIMAL |
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MODERATE |
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HIGH RISK |
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16. INITIAL TREATMENT GIVEN (X and complete as applicable) |
17. RECOMMENDED FURTHER PROPHYLACTIC TREATMENT |
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a. TIME |
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b. DATE (YYYYMMDD) |
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(X as applicable) |
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a. NONE |
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c. DEEP FLUSHING AND CLEANSING WITH SOAP AND WATER |
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b. HUMAN RABIES IMMUNE GLOBULIN |
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d. TETANUS PROPHYLAXIS |
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(Consult in accordance with Service/local policy prior to treatment) |
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(List dose given) |
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c. HUMAN DIPLOID CELL RABIES VACCINE |
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e. ASSESSMENT OF IMMUNOCOMPETENCE AND NEED FOR |
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d. COUNSELED ON INFECTIOUS RISK OF ORAL FLORA |
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ANTIBIOTIC USE |
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e. OTHER (Specify) |
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f. OTHER (Specify) |
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18. PHYSICIAN |
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a. NAME (Last, First, Middle Initial) |
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b. SIGNATURE |
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19. ARMY VETERINARIAN |
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b. NAME OF VETERINARIAN (If applicable) (Last, First, Middle Initial) |
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a. CONTACTED (X one) |
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YES |
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NO |
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20. VERBAL REPORT TO |
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(1) NAME (Last, First, Middle Initial) |
(2) TELEPHONE |
(1) NAME (Last, First, Middle Initial) |
(2) TELEPHONE |
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a. PM/PUBLIC |
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c. OTHER (List) |
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HEALTH |
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b. POLICE |
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PART III - MANAGEMENT OF BITING ANIMAL (To be completed by Veterinarian)
21.AUTHORITIES NOTIFIED (Local public health authorities, law enforcement, etc.)
a. NAME (Last, First, Middle Initial)
b.DATE
(YYYYMMDD)
c. TIME
d. INITIALS
e.
(1) DATE (YYYYMMDD) (2) TIME
22. INITIAL ACTION
23. FORM RECEIVED BY VETERINARY SERVICES
a. TIME |
b. DATE (YYYYMMDD) |
c. INITIALS |
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24.LOCATION OF ANIMAL DURING OBSERVATION PERIOD (On or off post, list point of contact if not veterinary activity)
25.OBSERVED BY (Include name of military or civilian agency)
26. DATES OBSERVED (YYYYMMDD)
a. FROM |
b. TO |
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27. DATE ANIMAL RELEASED FROM QUARANTINE (YYYYMMDD)
PATIENT'S IDENTIFICATION (ID impression, if available.) (For typed or written entries give name (Last, First, Middle Initial); pay grade; SSN; unit; duty and home telephone numbers; date; hospital or medical facility.)
DD FORM 2341, OCT 2007 |
Page 2 of 3 Pages |
PART III - MANAGEMENT OF BITING ANIMAL (Continued)
28.CONDITION OF ANIMAL DURING AND AT THE END OF
29.OTHER INFORMATION OR COORDINATION (Including notification of animal status to ER or MTF; list names and dates)
30. LABORATORY FINDINGS OF ANIMAL SUBMITTED FOR RABIES DIAGNOSIS
a. TEST (X one) |
b. DATE RECEIVED (YYYYMMDD) |
c. RESULTS (X one) |
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(1) FLUORESCENT ANTIBODY |
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NEGATIVE |
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POSITIVE |
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(2) CELL CULTURE |
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NEGATIVE |
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POSITIVE |
31. VETERINARY OFFICER
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE SIGNED
(YYYYMMDD)
PART IV - RABIES ADVISORY BOARD OR OTHER MEDICAL CONSULTATION/COORDINATION
32.DISCUSSED BY (List names, or X box at right.)
NOT REQUIRED TO MEET
33. RECOMMENDATIONS
a. HUMAN RABIES IMMUNE SERUM (X one) |
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LOCAL |
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SYSTEMIC |
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BOTH |
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b.VACCINE
c.OTHER
34.CHIEF, PREVENTIVE MEDICINE
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE SIGNED
(YYYYMMDD)
35. FINAL DISPOSITION OF CASE
36.MEDICAL OFFICER REVIEW (In accordance with Service/local policy) a. SIGNATURE
b. DATE SIGNED
(YYYYMMDD)
PATIENT'S IDENTIFICATION (ID impression, if available.) (For typed or written entries give name (Last, First, Middle Initial); pay grade; SSN; unit; duty and home telephone numbers; date; hospital or medical facility.)
DD FORM 2341, OCT 2007 |
Page 3 of 3 Pages |