Animal Bite Incident Report Form
Date of Bite:
*
/
Month
/
Day
Year
Date
Date of Report:
*
/
Month
/
Day
Year
Date
Person Reporting Incident
Bite Victim Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex:
Male
Female
Date of Birth:
*
/
Month
/
Day
Year
Date
Age:
Email
example@example.com
Parent/Guardian (if victim is a minor or an animal)
First Name
Last Name
Parent/Guardian Phone Number
-
Area Code
Phone Number
Parent/Guardian Email
example@example.com
Back
Next
Bite Incident Information
Where on the Body:
*
Address Where Bite Occurred (as much as you know)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Brief Synopsis of Events:
*
Back
Next
Biting Animal Information
(As much as you know)
Name of Pet:
Type of Animal:
*
Dog
Cat
Other
Sex of Animal:
*
Male
Neutered Male
Female
Spayed Female
Unknown
Breed:
*
Color(s):
*
Age:
Pet's Veterinary Clinic:
Back
Next
Owner Information
(As much as you know)
Name
First Name
Last Name
Owner's Phone Number
-
Area Code
Phone Number
Owner's Alt. Phone Number
-
Area Code
Phone Number
Owner's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Medical
Skin Broken:
*
Yes
No
Rabies PEP Given:
*
Yes
No
Date of Treatments:
*
/
Month
/
Day
Year
Date
Treatments:
*
Treatment Facility:
Treatment Facility Phone:
-
Area Code
Phone Number
Back
Next
Please attach a photo of the bite wound(s) sustained:
Browse Files
(Please make sure the file is in a .JPG, .PNG, or .BMP format for us to be able to open the image.)
Cancel
of
Please attach a photo of the animal that is responsible for the bite, if you have one:
Browse Files
(Please make sure the file is in a .JPG, .PNG, or .BMP format for us to be able to open the image.)
Cancel
of
Preview PDF
Submit
Should be Empty: