Department of Public Health
   
Animal Bite Report Form (* Required Fields)

Person Reporting Information
* First Name: * Last Name:
* Phone: 555-555-5555 Are you the victim? Yes No
Relationship to Victim:
Email:
 
Victim's Information
* First Name: * Last Name:
* Victim's DOB: MM/DD/YYYY Age:
* Victim's Address:
* City:   Add New City Here:
* State:      * Zip:     * Phone: 555-555-5555

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: (Sidewalk, Friend's House, etc...)
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: 555-555-5555
 
Animal Information
* Animal Type: (dog ,cat ,etc...) Breed: (pitbull, shepard, etc...)
Sex: Animal's Name:
 
Animal Owner's Information (if known)
First Name: Last Name:
Address:
City:      State:      Zip:
Phone: 555-555-5555

Please provide us with any additional comments

  

 
Public Health has made reasonable efforts to provide accurate translation. However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version.
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