Animal Bite Incident Report Form
Reporter info
Name of Reporter
First Name
Last Name
Organization if Applicable
Address of Reporter
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Report
-
Month
-
Day
Year
Date
Phone Number of Reporter
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Incident Information
Date of Incident
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Name of Bitten
First Name
Last Name
Address of Bitten
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Bitten
Please enter a valid phone number.
Format: (000) 000-0000.
Description of bite
Back
Next
Owner Information
Name of Owner
First Name
Last Name
Address of Owner
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Owner
Please enter a valid phone number.
Format: (000) 000-0000.
Type / Description of animal
Name of animal
Back
Next
Veterinarian information
Has the animal been vaccinated?
Yes
No
Unknown
Veterinarian who vaccinated
First Name
Last Name
Address of Veterinarian who vaccinated
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Confinement and Testing
Phone Number of Veterinarian
Please enter a valid phone number.
Format: (000) 000-0000.
Name of veterinarian office where confined
Address of where confined
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number where confined
Please enter a valid phone number.
Format: (000) 000-0000.
Date confinement began
-
Month
-
Day
Year
Date
Date can be released
-
Month
-
Day
Year
Date
Home confinement approved?
Yes
No
If animal sacrificed, lab where testes
Date Sent
-
Month
-
Day
Year
Date
Result of Test
Positive
Negative
Inconclusive
Additional Comments
Submit
Should be Empty: