Report form for unusual morbidity and/or mortality of wildlife, including wild birds suspected of avian influenza

Submission form

This is a form for people who wish to report unusual morbidity and/or mortality in wildlife.
Sometimes one may notice an unusual increase of the number of sick or dead wild animals. The DWHC would like to centralize this kind of information to generate a national overview of these observations.
Some of the reported cases may lead to further investigation by the research institutes affiliated with the DWHC. Should this occur, the submitter will first be contacted.
We would appreciate it if you could complete this form. Should you wish to consult one of our staff directly, you can contact us on telephone number +31-30-2537925, or e-mail address: dwhc@uu.nl

Submitter's details:
Name:	*
Position:
Organisation:
Address:
Postcode:
Residence :
Phone:
Fax:
E-mail:	*

Data about animals and circumstances:
Found in:
Nearest City or town:
Municipality:
Province:
Date or period:

Species (one or more):
Age:
Sex:

Number ill:	Estimated Counted
Number dead:	Estimated Counted

Population size of species in the area:

Description of the clinical signs and general condition of the affected animals:

Description of the cause of the unusual mortality/morbidity (if possible including start and end date of the problem):

If applicable, preventive measures, treatment and results:

Environmental factors that possibly played a role (e.g. weather conditions):

Other species (if possible with estimated numbers) present in the area:

Description of the area (e.g. land use, habitat type):

Organisations or individuals contacted:

Other comments:

Submission form

Submitter's details:

Data about animals and circumstances: