Bite Report (Initial)

Victim Information
Victim's First Name *
Victim's Last Name *
Street Address *
City *
State *
Apartment Number (if applicable)
Zip Code *
Phone Number * Please use the following format 248-555-1212
Email Address * Please enter correctly as this is the main way we will contact you
Confirm email
Date of Birth *
Drivers License Number *
Do you know who owns the animal? *	NoYes
Are you the owner of the animal that bit you? *	NoYes
Do you live in the home with the animal that bit you? *	NoYes
Animal Owner Information
Owner First Name *
Owner Last Name *
Street Address *
City *
State *
Apartment# *
Zip Code *
Phone Number *
Animal Information
Is the animal a stray animal? *	NoYes
What kind of animal were you bitten by? *	Dog Cat Bat Skunk Raccoon Oppossum Snake Other
Animal Breed *	Feral Domestic Short Hair Domestic Medium Hair Domestic Long Hair
Animal Breed	American Bull Dog Staffordshire Terrier Anatolian Shepherd Australian Cattle Dog(Blue/Red Heeler) Australian Shepherd Bassett Hound Beagle Berenese Mountain Dog Border Collie Boston Terrier Boxer Bull Terrier Cane Corso Catahoula Chihuahua Chow Chow Corgi Coonhound Dachshund(Weiner Dog) Dalmation Doberman English Bulldog German Shepherd German Shorthaired Pointer Golden Retriever Great Dane Great Pyrenees Greyhound Husky Jack Russell Labrador Retriever Maltese Mastiff Mixed breed Mountain Cur Newfoundland Pitbull Pomeranian Poodle Pug Rat Terrier Rottweiler St Bernard Schnauzer Shih Tzu Terrier Weimaraner Whippet Yorkie
Animals Name (If Applicable)
Animal Gender *	Male Female Unknown
Animal Size *	Small Medium Large
Is the animal up to date on shots? *	Yes No Unknown
Bite Information
What kind of bite occurred? *	Animal vs Animal Animal vs Adult Animal vs Child
What is the address where the bite occurred? * Include City and State
City *
State *
Zipcode *
Where did the animal bite you? * Select All That Apply	Face Neck R Shoulder L Shoulder Chest Abdomen R Arm L Arm Back R Thigh L Thigh R Calf L Calf R Foot L Foot R Hand L Hand Buttocks Genital Region Finger
How severe was the bite? *	Level 1 (Skin contact without puncture) Level 2 (Single bite with shallow punctures) Level 3 (Single bite with one or more deep punctures or lacerations) Level 4 (Mulitple level 3 bites or a sustained attack) Level 5 (Fatal Attack - resulting in death of victim - person or animal)
Did you seek medical treatment? *	NoYes
Where did you seek medical treatment? *
How did the bite occur? * Include any details about the incident
Any additional information we should know?
Photos/Evidence *
Photos/Evidence
Photos/Evidence