Name of person completing this form:

Telephone:

e-mail:

State where incident happened (State postal code):

Sex of victim: / Male / Female

Age of Victim: / Under 10 years / Between 10 y.o. and 17.y.o. / Adult

Date of Incident: / Within the last 3 mos./ Within the last 6 mos. / Within the last year

Breed of dog involved in attack:

How familiar was the victim with the dog? / Very familiar / Somewhat familiar / Did not know dog

Did the owner of the dog own the property where the dog resided? / Yes / No / Uncertain

Where was the victim bitten?

Did the victim receive medical treatment from a physician? / Yes / No

Additional details (please be brief)