Dog Bite Incident Report

Instructions

Complete the following to report a dog bite or scratch.

Victim Contact Information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

County *

Enter your county's name *

Home Phone *

Work Phone *

Mobile Phone *

Email *

Dog Information

Enter the dog's name *

Color of dog *

Sex of Dog *

Is the dog spayed or neutered? *

Select the dog's approximate age *

Does this dog have a rabies tag? *

Enter the rabies tag number *

Attack Information

Date of Attack *

Time of Attack *

Type of attack *

General location where attack occurred *

Enter the zip code where the attack occurred *

What were the circumstances of the attack? *

Describe the circumstance *

Select the dog's behavior prior to the attack: *

Does this dog have a prior bite history? *

Describe the circumstances leading to bite or scratch. Be Specific. *

Was the veterinarian contacted? *

Has the dog been quarantined? *

Where is the dog quarantined? *

Enter the name of the quarantine location *

Injury Information

Where on the person's body did the injury occur? *

Was the skin broken? *

What type of injury? *

Describe the injury *

Was medical attention required? *

What type of medical attention was 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 *

Signature Date *

Click submit once. It may take up to 30 seconds for the screen to change. Do not click submit more than once.

Instructions Complete the following to report a dog bite or scratch.
Victim Contact Information
First Name *
Last Name *
Address *
City *
State *
Zip Code *
County *
Enter your county's name *
Home Phone *
Work Phone *
Mobile Phone *
Email *
Dog Information
Enter the dog's name *
Color of dog *
Sex of Dog *
Is the dog spayed or neutered? *
Select the dog's approximate age *
Does this dog have a rabies tag? *
Enter the rabies tag number *
Attack Information
Date of Attack *
Time of Attack *
Type of attack *
General location where attack occurred *
Enter the zip code where the attack occurred *
What were the circumstances of the attack? *
Describe the circumstance *
Select the dog's behavior prior to the attack: *
Does this dog have a prior bite history? *
Describe the circumstances leading to bite or scratch. Be Specific. *
Was the veterinarian contacted? *
Has the dog been quarantined? *
Where is the dog quarantined? *
Enter the name of the quarantine location *
Injury Information
Where on the person's body did the injury occur? *
Was the skin broken? *
What type of injury? *
Describe the injury *
Was medical attention required? *
What type of medical attention was 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 *
Signature Date *
Click submit once. It may take up to 30 seconds for the screen to change. Do not click submit more than once.