Survey - Bite Report - San Diego Humane Society

Please use the below form to report an animal bite that caused injury to a human. To notify San Diego Humane Society Law Enforment of an animal biting another animal, please use this form.

To fill out the paper form, please print this PDF file.

Please provide your contact information:

This form was completed by:

*

Name:

First Required	Last Required

*

Email: Required

Street 1:

City/State/ZIP:

City	State	ZIP

*

Mobile Phone: Required

Date of Birth:

Yes, I would like to receive e-mail from San Diego Humane Society

Yes, I would like to receive postal mail from San Diego Humane Society

Please provide information about the bite victim:

This form is to report an animal bite resulting in injury to a human. To notify San Diego Humane Society Law Enforment of an animal biting another animal, please use this form.

*

Question - Required - Who was bitten?
Please make between 1 and 2 selections from the choices below.

	Yourself
	Another Person

*

Question - Required - Victim's Full Name:

Question - Not Required - Gender:

*

Question - Required - Victim's Date of Birth:

Month

Day

Year

Question - Not Required - Parent or Guardian's full name (if victim is a minor):

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Victim's Street Address:

Question - Not Required - Apt #:

*

Question - Required - City:

Question - Not Required - Zip:

Question - Not Required - Victim's Phone #:

Question - Not Required - Alternative Phone #:

Bite Information

*

Question - Required - Address / Location where Bite Occurred:

*

Question - Required - Area of Body Affected:

*

Question - Required - Severity of Bite: Minor
Moderate
Severe

*

Question - Required - Time of Bite:

Question - Not Required - Date of Bite:

Month

Day

Year

*

Question - Required - Did the Bite Break Skin: Yes
No

Circumstance of Bite

*

Question - Required - Incident Details:

Hospital Information

Question - Not Required - Name of Hospital:

Question - Not Required - Hospital Street Address:

Question - Not Required - Hospital Phone #:

Question - Not Required - Name of Physician:

Question - Not Required - Date of Visit:

Month

Day

Year

Animal Owner Information

Question - Not Required - Name:

Question - Not Required - Address:

Question - Not Required - Apt #

Question - Not Required - City:

*

Question - Required - State: CA

*

Question - Required - Zip:

Question - Not Required - Dog Owner's Telephone Number:

Animal Description Information

Please describe te animal that caused the injury.

Question - Not Required - Type of Animal:

Question - Not Required - Breed of Animal:

Question - Not Required - Sex of Animal: Male
Female

Question - Not Required - Animal Name:

Question - Not Required - Animal Color:

Question - Not Required - Animal Age:

* Are feilds we need filled out before you can submit this form.