• 
  

• Animal Bite Reporting Form

• 
  
• Today's Date*
• Person Reporting*
• Address*

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Phone*

  --
• Email*
• Relationship to Victim* Select Family Neighbor Witness Healthcare Facility Law Enforcement None
• 
  
• Victim Name*
• Date of Birth*
• Address*

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Phone*

  --
• 
  

• ---

• 
  
• Date Bite Occurred*
• Time*

  :AMPM
• Location of Incident*
• Type of Animal (please give as much detail as possible)*
• To your knowledge, was the animal wild or domesticated?*

  Wild Domesticated
• Current Status of Animal (choose all that apply)*

  Owned/In Possession of Victim Owned/In Possession of Other Stray/Feral Location Unknown In Possession of Animal Control Euthanized Quarantined Awaiting Testing
• 
  
• Please describe the incident/how the bite occurred.*
• Please describe the wound and any treatment received.*
• Additional Comments
•