Animal Bite Incident Report Form

Animal Bite Incident Report Form
Date of Bite:*

MonthDayYear
Date
Date of Report:*

MonthDayYear
Date
Person Reporting Incident
Bite Victim Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex:

MaleFemale
Date of Birth:*

MonthDayYear
Date
Age:
Email
example@example.com
Parent/Guardian (if victim is a minor or an animal)

First NameLast Name
Parent/Guardian Phone Number

Area CodePhone Number
Parent/Guardian Email
example@example.com

Bite Incident Information
Where on the Body:*
Address Where Bite Occurred (as much as you know)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Brief Synopsis of Events:*
Biting Animal Information

(As much as you know)
Name of Pet:
Type of Animal:*

DogCatOther
Sex of Animal:*

MaleNeutered MaleFemaleSpayed FemaleUnknown
Breed:*
Color(s):*
Age:
Pet's Veterinary Clinic:
Owner Information

(As much as you know)
Name

First NameLast Name
Owner's Phone Number

Area CodePhone Number
Owner's Alt. Phone Number

Area CodePhone Number
Owner's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical
Skin Broken:*

YesNo
Rabies PEP Given:*

YesNo
Date of Treatments:*

MonthDayYear
Date
Treatments:*
Treatment Facility:
Treatment Facility Phone:

Area CodePhone Number

Please attach a photo of the bite wound(s) sustained:

Browse Files
(Please make sure the file is in a .JPG, .PNG, or .BMP format for us to be able to open the image.) Cancelof
Please attach a photo of the animal that is responsible for the bite, if you have one:

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(Please make sure the file is in a .JPG, .PNG, or .BMP format for us to be able to open the image.) Cancelof
Should be Empty: