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Animal Bite Report Form

Officially document animal bite incidents, including details about the victim, the animal, and the medical care provided.

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Date of Report*

Who Is Reporting?*

Victim Witness Healthcare Provider Animal Owner Law Enforcement

Healthcare Facility*

Name of Facility

Name of Reporter

First Name

Last Name

Reporter Contact*

Date of Bite*

Time of Bite

Location Where Bite Occurred*

Has Law Enforcement Been Notified?*

Yes No

Reason Law Enforcement Was Not Notified*

Victim Name*

First Name

Last Name

Victim Date of Birth*

Victim Address

Street Address

City

State / Province

ZIP / Postal Code

Victim Phone Number*

Type of Animal*

Dog Cat Wild Animal Livestock Other

Select Wild Species*

Raccoon Bat Fox Coyote Skunk Other

Select Domestic Species*

Dog Cat Rabbit Ferret Other

Disposition of Animal

Quarantined Euthanized Released Unknown Deceased

Rabies Vaccination Status

Up to Date Expired None Unknown

Date of Last Rabies Vaccination

Name of Owner (If Different Than Victim)

First Name

Last Name

Owner's Phone Number

Documentation of How the Bite Occurred.

Description of Wound and Treatment Provided

Additional Comments

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