Suspected Maltreatment Report
Complainant Information:
Date of Complaint
-
Month
-
Day
Year
Date
Complainant Name
First Name
Last Name
Complainant Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Complainant Phone Number
Please enter a valid phone number.
Email
example@example.com
Complaint Details
Is this the first report?
Yes
No
Date of Prior Report
-
Month
-
Day
Year
Date
Evidence?
Yes
No
Type of Evidence
Photo
Video
Other
Evidence File Upload
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Is complainant willing to sign an affidavit and testify in court?
Yes
No
If no, why not?
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Pet Owner Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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Animal Information
Animal Name
Species
Dog
Cat
Other
Breed
Color
Age
Sex
Male
Female
Unknown
Spay / Neuter?
Yes
No
Unknown
Does the animal have a primary Veterinarian?
Yes
No
Unknown
Name of Veterinarian
City, State of Veterinarian
Up to date on Rabies?
Yes
No
Unknown
Does the animal have any chronic illness?
Yes
No
Unknown
If yes, please describe
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Officer Findings
Officer Name
First Name
Last Name
Date of visit
-
Month
-
Day
Year
Date
Is Animal located at Owner's above stated address?
Yes
No
If no, Where is animal located?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Animal main living area
Inside
Outside
Unknown
Inside Condition
Crated
Free Roam
Unknown
Outside Condition
Outside Pen
Tethered
Free Roam
Unknown
Living conditions
Clean
Needs Improvement
Satisfactory
Unacceptable
Unknown
Access to fresh water?
Yes
No
Unknown
Access to food?
Yes
No
Unkown
Food Routine
Once a day
Twice a day
Three times a day
Free Feed
Animal behavior with owner
Excited
Happy
Neutral
Cautious
Scared
Animal behavior with Officer
Excited
Happy
Neutral
Cautious
Scared
Coat Condition
Clean
Dirty
Groomed
Ungroomed
Nail Condition
Short
Long
Affecting Gait
Body Condition Score
1
2
3
4
5
6
7
8
9
1 is , 9 is
Visible Wounds/Scars/Bruises?
Yes
No
If so, please describe
Additional Comments
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Will a follow up be required?
Yes
No
If no, why?
Citation issued?
Yes
No
Please specify:
Submit
Should be Empty: