Animal Bite Report – County of Saratoga, New York

DoH Animal Bite 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

Type of Incident (Bite, Exposure, Other)

Did the Victim get Medical Attention?

Yes

Treatment Required

Treatment Location

Treatment Date

SECTION III: ANIMAL OWNER INFORMATION

Owner Name

County of Residence

Owner Phone

Owner Email

Owner Address

City

State

Zip Code

Person Completing Sections I, II, III

Date

Additional notes regarding the incident

SECTION IV: RABIES VACCINATION / ANIMAL CONTROL INFORMATION

Animal Name

Age

Animal Description

Veterinarian Name

Veterinarian Phone

Vaccination Date

Is owner known to the bite victim?

Yes

Unknown