Tick Bite Incident Report Form
Report details of a tick bite incident accurately and concisely.
Incident date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of bite (e.g., park, backyard, trail)
*
Person affected (full name)
*
First Name
Last Name
Activity being performed at the time
*
Please Select
Walking
Hiking
Gardening
Playing
Camping
Other
Estimated time tick was attached (hours)
Body area bitten
*
Please Select
Leg
Arm
Torso
Head/Neck
Other
Was the tick removed?
*
Yes
No
Tick removal method (if removed)
Please Select
Tweezers
Removed by hand
Doctor/clinic
Other
Immediate symptoms or reactions observed
Redness
Swelling
Pain
Rash
None
Other
Additional incident details
Submit Report
Should be Empty: