Vicious Dog Form
Activity Number:
Bite Report Number:
Date of Incident:
*
/
Month
/
Day
Year
Date
Complainant Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Victim Information
(If animal victim or different from Complainant)
Name:
*
Phone Number:
Alternate Phone Number:
Color (if animal):
Sex (if animal):
Male
Female
Breed (if animal):
Vicious Animal Information
(As much as you know)
Animal's Name:
Animal's Age (years):
Animal's Color(s):
*
Breed:
*
Animal's Sex:
Female
Male
Spayed/Neutered
Yes
No
Owner Information
(As much as you know)
Owner's Name:
Owner's Phone Number:
-
Area Code
Phone Number
Owner's Alt. Phone Number:
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vet Clinic & Phone #:
Description of Incident
For the description of the incident, be sure to include the name of the victim, description of the attacking animal, whether the attack was provoked or not, date of the incident, the physical address where the incident occurred, and injuries sustained during the incident. Be sure to provide enough information to form a clear picture of what occurred at that time.
Describe the events leading up to and during the incident:
*
Administrative Section
Please sign electronically to the best of your ability. Your signature here authorizes MACC to use your e-signature as though you have physically signed the document.
Signature
*
Clear
Printed Name
*
Date
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
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