Incident Report
Your Name
*
First Name
Last Name
Date of Incident:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Approximate Time of Incident:
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Hour Minutes
AM
PM
AM/PM Option
Location:
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Please Select
Houston Greater Good Clinic
Humble Clinic
Spring Clinic
Tomball Clinic
Resale Shop
Other
Describe what best fits:
*
Please Select
Abandoned animal
Injury to an employee
Injury to a customer
Injury or death of an animal during or after a medical procedure
Injury to an animal not involving a medical procedure
Other
Is there a video of the incident?
*
Please Select
Yes
No
Unknown
Type of Injury
*
Please Select
Animal Bite
Needle Puncture
Slip & Fall
Other
Is the person seeking medical attention?
*
Please Select
Yes
No
Chubb Claim Number:
*
You must get a claim number from Chubb for the person seeking medical attention.
Name of Injured Person:
*
First Name
Last Name
Job Title of Injured Person:
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Please Select
Vet Technician
Veterinarian
Sales Clerk
Manager
Name and address of the clinic where medical attention was sought.
*
List all employees involved or witnessed the incident.
*
You must obtain a witness statement from each.
List all customers involved or witnessed the incident. Include first and last names and phone numbers.
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You must obtain a witness statement from each.
Name and Description of Animal(s) Involved. Include Owner Information (Name, Address, Phone Number)
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Suspect's Description
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Describe what happened.
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Describe injury.
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Describe the overall condition of the animal(s).
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What actions were taken?
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Veterinarian's Examination/Findings.
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Medical Record Updated
*
Check here confirming that all notes have been entered into the patient's medical record.
Outcome of the animal.
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Upload witness statements, videos, photos, and any other supporting documentation to Dropbox.
*
Please Select
I have uploaded all documents.
I am working on collecting and uploading all documents.
There are no documents to upload.
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