重庆市动物疫病追踪流行病学调查表

年月曰编号:调查日期:场/户/养殖小区启用时间/检查站名称畜（货）主*/负责人姓名联系电话邮编联系地址周围有无畜禽群发生类似疫病口无口有口本村口本乡/镇/街道口本区/县；具体地址______________________________________________________________________________发病动物种类________________________________________________发病时间________________发病简要情况__________________________________________________________________________疫点内的周围有无野生动物发生类似疫病口无口有口本村口本乡/镇/街道口本区/县；动物到达具体地址______________________________________________________________________________本发病动物种类________________________________________________发病时间________________地21天内发病简要情况__________________________________________________________________________周围发病情况周围有无人感染/发生人畜共患病口无口有口本村口本乡/镇/街道口本区/县；具体地址___________________________________________________发病时间________________发病简要情况__________________________________________________________________________疫点密切接触人员发病情况______________________________________________________________重庆市动物疫病追踪流行病学调查表疫点内名称________________地点____________________数量_______________时间___________的动物名称________________地点____________________数量_______________时间___________到达本名称________________地点____________________数量_______________时间___________地21名称________________地点____________________数量_______________时间___________天内畜名称________________地点____________________数量_______________时间___________禽及产名称________________地点____________________数量_______________时间___________品的流向疫点内名称口垫料口饲草口饲料及其原料口药品口器械口饲养工具口车辆口其它___________________数的动物量___________________________________________________________________________________流到达本出前经过何种处理_____________________________________________________________________目地21的地_________________________________________________________________________________经天内可疑过或存放地___________________________________________________________________________使污染物的用情况_______________________________________________________________________________流向姓名:_________________________________________________________________________________疫点内日期________________________________________________________________________________的动物职业________________________________________________________________________________到达本联系电话_____________________________________________________________________________地天内21去往何地_____________________________________________________________________________从本场外接触畜禽_____________________________________________________________________________出的人员无害化处理口焚烧口深埋口焚烧+深埋口密闭发酵口化制口其它__________________________________________________________________病、死动扔在野外口江河、小溪口池塘、水库口山谷/沟口田地口其它______________________________物，流自己食用_____________________________________________________________________________产胎儿、出售数量_______________________时间___________收购地点______________________死禽胚处理情运输工具___________牌照号码_____________运往何地_____________________况收购单位/人员_____________________________________________________________其它_________________________________________________________________________________疫点内带毒口否口是；活动范围的动物到达本储存宿主名称—________________________检测单位_______________________________地21检测方法:带毒口否口是；活动范围天内自中间宿主名称________________________检测单位_______________________________然宿主检测方法:带毒情是否使用口否口是种类;年龄;数量封锁开始时间;结束时间;封锁时间疫点内期间检测结果;检测方法的动物检测单位______________________________________________________________________________到达本地是否使用口否口是种类21解除—;年龄;数量天内岗八开始时间;结束时间;解除封锁时间封锁哨动物检测结果________________________________________检测方法__________________________后情况检测单位初步调查结果及分析被调查被调查人__________________________（签名/盖章）联系电话_______________________人与被调查人__________________________（签名/盖章）联系电话_______________________单位被调查单位________________________________（盖章）联系电话_______________________姓名_________________________________联系电话调查人单位__________________________（盖章）备注必要时，可附加文字材料补充说明自然村集中发病的疫点，畜主可只填村社干部或村级防疫员/疫情报告观察员。