Animal Bite Report – County of Saratoga, New York

Saratoga County Department of Health
Animal Bite/Incident Report

SECTION I

Report Source (hospital, MD, ACO, Vet office, etc):

Report Source Phone

Report Date

SECTION II: VICTIM INFORMATION

Date of Bite

Victim Name

Date of Birth

County of Residence

Victim Address

City

State

Zip Code

Parent/Guardian Name (if victim is under 18)

Victim Phone

Victim Email

Type of Animal Involved

Location of Wound

Did the Victim get Medical Attention?
Yes No

SECTION III: ANIMAL OWNER INFORMATION

Owner Name

County of Residence

Owner Phone

Owner Email

Street Address

City

State

Zip Code

Person Completing Sections I, II, III

Completion Date

Please submit additional notes regarding the incident

SECTION IV: RABIES VACCINATION / ANIMAL CONTROL INFORMATION

Animal Name

Age

Animal Description

Vaccination Date

Is owner known to the bite victim?
Yes No Unknown

Veterinarian Name

Veterinarian Phone