Dog Bite Incident Report

Instructions Complete the following to report a dog bite or scratch.
Victim Contact Information
First Name * Enter your first name
Last Name * Enter your Last Name
Address * Enter your address
City * Enter your city
State * Select your state.
Zip Code * Enter your zip code.
County * Select your county. If your county is not listed, select Other
Enter your county's name * Enter your county's name.
Home Phone * Use format: xxx-xxx-xxxx
Work Phone * Use format: xxx-xxx-xxx
Mobile Phone *
Email * Use format: user@domain.com
Dog Information
Enter the dog's name * Enter the dog's name
Color of dog * Select the color of the dog.
Sex of Dog * Select the sex of the dog.
Is the dog spayed or neutered? * Select the dog's altered status.
Select the dog's approximate age * Select the dog's approximate age.
Does this dog have a rabies tag? * Select an option.
Enter the rabies tag number * Enter the rabies tag number
Attack Information
Date of Attack * Select the date the attack occurred.
Time of Attack * Select the time the attack occurred.
Type of attack * Select the attack type.
General location where attack occurred * For example, in the foster's home, at the park, in the backyard, etc
Enter the zip code where the attack occurred * Enter the zip code where the attack occurred.
What were the circumstances of the attack? * Select the option that best describes the circumstances around the attack.
Describe the circumstance * Be generic. You'll describe the attack shortly.
Select the dog's behavior prior to the attack: * Select an option.
Does this dog have a prior bite history? * Select an option.
Describe the circumstances leading to bite or scratch. Be Specific. * Describe the circumstances. Be specific.
Was the veterinarian contacted? * Select an option.
Has the dog been quarantined? * Select an option.
Where is the dog quarantined? * Select an option.
Enter the name of the quarantine location * For example, Grand Park, BARC, Harris County, or foster's name.
Injury Information
Where on the person's body did the injury occur? * Select the general area where the injury was sustained.
Was the skin broken? * Select an option.
What type of injury? * Select an option.
Describe the injury * For example, bite to the ear on the left side of the face.
Was medical attention required? * Select an option.
What type of medical attention was required? * Select an option
Describe the type of medical attention required * Describe the type of medical attention required.
Signature By submitting this report I certify that the above information is true and correct under the penalties of perjury. I am aware that any false information may result in nullifying this report and legal action may be taken. I will not hold Houston Area Doberman Rescue, Inc. or any of its representatives, volunteers or agents financially or legally responsible for any injury. If you are using a phone or tablet to complete this application, simply sign your name below. If you are using a computer, use your mouse to write your name below.
Signature * Sign Here
Signature Date * Select today's date
Click submit once. It may take up to 30 seconds for the screen to change. Do not click submit more than once.

Dog Bite Incident Report

Instructions

Victim Contact Information

Dog Information

Attack Information

Injury Information

Signature