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.
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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.
Description of bite
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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.
Type / Description of animal
Name of animal
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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
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Confinement and Testing
Phone Number of Veterinarian
Please enter a valid phone number.
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.
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: