Animal Bite Reporting Form
Date of Report
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who is Reporting
*
Healthcare Facility
Citizen
Law Enforcement
Other
Healthcare Facility
*
Please Select
Barrett Hospital ER
Barrett Hospital Clinic
Beaverhead Urgent Care
Blacktail Medical Clinic
Other
Name of Facility
Name of Reporter
First Name
Last Name
Reporter Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Bite
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Bite
Hour Minutes
AM
PM
AM/PM Option
Location where bite occurred
*
Has law enforcement been notified?
*
Yes
No
Reason Law Enforcement not notified
*
Victim Name
*
First Name
Last Name
Victim DOB
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Victim Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Victim Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Animal
*
Domestic
Wild
Select Wild Species
*
Bat
Skunk
Fox
Wolf hybrid
Raccoon
Rodent
Other
Select Domestic Species
*
Dog
Cat
Ferret
Horse
Cow
Other
Disposition of Animal
Owned by victim
Owned by other
Stray/ feral
Location unknown
Alive and in Quarantine
Euthanized
Waiting to be tested
Rabies Vaccination Status
Up to date and documented
Not Vaccinated
Unknown
Date of last Rabies Vaccination
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Owner (if different than victim)
First Name
Last Name
Owner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Documentation of how bite occurred.
Description of Wound and Treatment provided
Additional Comments
Submit
Should be Empty: