Instructions: Use this log to record all tick bites received during the calendar year. Submit to supervisor and keep a copy for your file. Supervisor will retain for five years. Note: If tick bite requires medical attention, follow standard injury/reporting procedures.
Employee Name:	Calendar Year:
SECTION 1 – Bite Information
Date of Bite	Time of Bite	Zip Code/County/City Where Bite Occurred	Describe What You Were Doing at Time of Bite	Part of Body Where Bite Occurred	Name of Witness
SECTION 2 – Signature
VDOF Employee Name (Print)	VDOF Employee Signature	Date
Supervisor Name (Print)	Supervisor Signature	Date