Bite Incident Form

Contact Information

Who's filling this out?

Please select... Victim Witness Parent/Guardian Other

Please provide details

Relationship to PAWS

Please select... Adopter Foster Employee Visitor Volunteer Other

Please provide details

First Name

Last Name

Email

Phone

Address

Please select... ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Incident Information

Was this incident against a human or animal?

Please select... Human Animal

Animal Species

Please select... Dog Cat

Animal Name

Animal Number

Victim First Name

Victim Last Name

Victim Email

Victim Phone

Victim Relationship to PAWS

Please select... Adopter Foster Employee Visitor Volunteer Other

Please provide victim relationship details

Witness First Name

Witness Last Name

Witness Email

Witness Phone

Witness Relationship to PAWS

Please select... Adopter Foster Employee Visitor Volunteer Other

Please provide witness relationship details

Did the victim seek medical attention?

Please select... Yes No n/a

Doctor / hospital information

Did the bite break skin?

Please select... Yes No

Where did the bite/incident take place?

Please select... Adoption Center Medical Center Home Other

Please explain

Please describe the appearance and location of the bite/incident and attach photos if the skin was broken

File 1

File 2

File 3

Injuring Animal Information Prior to the Incident

Prior to the incident was the injuring animal making noise, such as barking, hissing, or yowling?

Please select... Yes No Uncertain

Prior to the incident, what did the injuring animal's eyes look like?

Please select... Loosely Gazing Staring Intently Uncertain

Prior to the incident, what did the injuring animal's face look like?

Lips tightenedMouth LooseShowing TeethBrow FurrowedBrow RelaxedUncertain

Prior to the incident, what did the injuring animal's ears look like?

Upright and AlertTurned SidewaysPressed Flat Against the HeadUncertain

Prior to the incident, what was the injuring animal's body language?

Hiding or RetreatingMoving ForwardBody StiffBody RelaxedMoved Quickly Towards VictimUncertain

What was the injuring animal doing before the incident? Please include if they were eating or playing with a toy.

Injuring Animal Information During the Incident

During the incident was the injuring animal making noise, such as barking, hissing, or yowling?

Please select... Yes No Uncertain

During the incident, what did the injuring animal's eyes look like?

Please select... Loosely Gazing Staring Intently Uncertain

During the incident, what did the injuring animal's face look like?

Lips tightenedMouth LooseShowing TeethBrow FurrowedBrow RelaxedUncertain

During the incident, what did the injuring animal's ears look like?

Upright and AlertTurned SidewaysPressed Flat Against the HeadUncertain

During the incident, what was the injuring animal's body language?

Hiding or RetreatingMoving ForwardBody StiffBody RelaxedMoved Quickly Towards VictimUncertain

What was the injuring animal doing during the incident? Please include if they were eating or playing with a toy.

Injuring Animal Information After the Incident

After the incident was the injuring animal making noise, such as barking, hissing, or yowling?

Please select... Yes No Uncertain

After the incident, what did the injuring animal's eyes look like?

Please select... Loosely Gazing Staring Intently Uncertain

After the incident, what did the injuring animal's face look like?

Lips tightenedMouth LooseShowing TeethBrow FurrowedBrow RelaxedUncertain

After the incident, what did the injuring animal's ears look like?

Upright and AlertTurned SidewaysPressed Flat Against the HeadUncertain

After the incident, what was the injuring animal's body language?

Hiding or RetreatingMoving ForwardBody StiffBody RelaxedMoved Quickly Towards VictimUncertain

What was the injuring animal doing after the incident? Please include if they were eating or playing with a toy.

Incident Environment

On what approximate date did the incident occur?

At approximately what time did this incident occur?

Please select... 12:00 12:15 12:30 12:45 1:00 1:15 1:30 1:45 2:00 2:15 2:30 2:45 3:00 3:15 3:30 3:45 4:00 4:15 4:30 4:45 5:00 5:15 5:30 5:45 6:00 6:15 6:30 6:45 7:00 7:15 7:30 7:45 8:00 8:15 8:30 8:45 9:00 9:15 9:30 9:45 10:00 10:15 10:30 10:45 11:00 11:15 11:30 11:45

 

Please select... AM PM

Who was present?

Was someone interacting with or touching the animal?

Please select... Yes No

What specific location did this incident occur? (ie Kitchen, Living Room, Yard, etc.)

What else was going on around you when the incident occurred?

Was the environment quiet or noisy?

Please select... Quiet Noisy

Were animals or food in the area?

Please select... Animals Food Both Neither

Please describe any additional details surrounding the incident.

By clicking the 'Submit' button on this form, you attest that all information contained within this incident report is of your own impressions, observations, and recollections. You have not been in any way influenced to alter your responses in any way. Please Confirm.

Please select... Yes No

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