Department of Public Health

Person Reporting Information
* First Name: * Last Name:
* Phone: 555-555-5555 Email:
* Reporting Agency:
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
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 Occured:
* City:      State:      Zip:

Describe How the Bite Occurred:

Victim's Treatment Information
Location of Wound:
Treatment Description:
Was victim Hospitalized? YesNo
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:   Color: Animal's Name:
* Animal Impounded? Yes No Impound No.:
Taken to clinic for treatment? Yes No Clinic Name:
Clinic Address: Clinic Phone:
Current Rabies Vaccination? Yes No Date Vaccinated:
Animal Sterilized? Yes No Animal Died? Yes No
Animal Licensed? Yes No License Number:
License Expiration Date: City/County License in:
Euthanized? Yes No Date Euthanized:
Specimen ready for pickup? Yes No Shelter:
Animal Owner's Information (if known)
First Name: Last Name:
City:      State:      Zip:
Phone: 555-555-5555
Please provide us with any additional comments
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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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