Veterinary Public Health

Animal Bite Report Form (* Required Fields)

Person Reporting Information

*First Name:

* Last Name:

*Phone:

Email:

Are you the victim? Yes No

Relationship to Victim:

Victim's Information

*First Name:

*Last Name:

*Victim's DOB:

Age:

*Victim's Address:
* Phone:

* City:
Add New City Here:

* State:

* Zip:

Location of Bite (check all that apply):

Face (head, neck, lip, etc.)

Arm (shoulder, elbow, etc.)

Hand (wrist, palm, fingers, etc.)

Torso (stomach, back, etc.)

Pelvic region (buttocks, hips, etc.)

Leg (knee, thigh, etc.)

Foot (ankle, heel, toes, etc.)

Unknown

Other:

Which side of the body is bite located?

Left

Right

Both

Unknown

Bite Information

* Date of Bite:

Time of Bite (HH):

(MM):

AM PM

Where Bite Occurred:

Nearest Address or Cross Street Where Bite Occurred:

City:

State:

Zip:

Describe How the Bite Occurred:

Victim's Treatment Information

Type of treatment (check all that apply):

Antibiotics

Wound care

Tetanus (Tdap) vaccine

Pain management

Sutures

Surgery

Rabies PEP

Other:

Treated by: (if known)

Physician or Facility Name:

Date of Treatment:

Phone:

Animal Information

* Animal Type: (dog ,cat ,etc...)

Breed:(pitbull, shepherd, etc...)

Sex:

Animal's Name:

Animal Owner's Information (if known)

First Name:

Last Name:

Phone:

Address:

City:

State:

Zip:

Please provide us with any additional comments