Date of Attack
-
Month
-
Day
Year
Date
About the Victim
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
Occupation
Height
Weight
Gender
Male
Female
N/A
Color of exposed skin
Body Full Clothed?
Yes
No
Type and color of clothing
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About the Shark(s)
Species of Shark
Identified By
Number of Sharks Involved
Description of shark(s)
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About the Attack
Location of the Attack
Longitude
Latitude
Distance from Shore
Depth of Attack
Time of Day
Water Temp
Air Temp
Temperatures
Estimated
Measured/Taken
Weather conditions
Sea conditions
Water visibility
Water depth at attack location
Description of ocean floor at attack location
Deep water channel or drop off at attack location
Yes
No
If yes, distance from attack location
Kelp present at attack location
Yes
No
Distance from kelp
Amount and location of kelp
Were marine mammals present at or near attack location?
Yes
No
If yes, location, number, and species of animals:
Unusual behavior of fishes, birds or marine mammals prior to attack
Yes
No
If yes, type of animal and behavior observed:
Collecting of marine animals prior to attack
Yes
No
Type of animals collected prior to attack:
Number of marine animals collected prior to attack
Method of collection and length of time
Aware of sharks presence prior to attack:
Yes
No
Aware of prior attacks at the same location:
Yes
No
Sharks sighted at this location prior to your attack:
Yes
No
If yes, date of previous sighting
-
Month
-
Day
Year
Date
Witness to previous shark sighting
Attack description: Describe in detail the movement and behavior of the shark and victim prior to, during, and following the attack. Describe rescue, nature of injury, emergency and subsequent medical treatment
Activity at time of attack
Length of time in water prior to attack
Describe type and color of equipment used in this activity
Victim's Recovery
Yes
No
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Injury and Medical Care
Photographs of Injury
Yes
No
Photographer's Name
First Name
Last Name
Photographer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital Name
Hospital Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital Phone
Attending Physician
Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician's Phone
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Witness(es)
Name
Address
Phone
Witness 1
Witness 2
Witness 3
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Agreement
I understand that upon submission of this form I will have donated the above data to Ralph S. Collier and/or the Shark Research Committee for their ongoing white shark research projects including white shark/human interactions from the Pacific Coast of North America. I voluntarily donate this information to further our knowledge of the white shark and its interactions with humans.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Email
example@example.com
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