Survey - Bite Report - San Diego Humane Society

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Bite Report

Form Completed by (Please provide your contact information):

1.

Completed By:

*

Name:

First Required	Last Required

*

Email: Required

Street 1:

City/State/ZIP:

City	State	ZIP

*

Mobile Phone: Required

Gender:

Date of Birth:

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

Victim Information

*2.

Question - Required - Who was bitten?
Please make between 1 and 3 selections from the choices below.

	Yourself
	Your Dog
	Other

*3.

Question - Required - Victim's Full Name:

*4.

Question - Required - Victim Date of Birth:

Month

Day

Year

5.

Question - Not Required - Victim Street Address:

6.

Question - Not Required - Apt #:

*7.

Question - Required - City:

8.

Question - Not Required - Zip:

9.

Question - Not Required - Victim Phone #:

10.

Question - Not Required - Alternative Phone #:

Bite Information

*11.

Question - Required - Address / Location where Bite Occurred:

*12.

Question - Required - Area of Body Affected:

*13.

Question - Required - Severity of Bite: Minor
Moderate
Severe

*14.

Question - Required - Time of Bite:

15.

Question - Not Required - Date of Bite:

Month

Day

Year

*16.

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

Circumstance of Bite

*17.

Question - Required - Incident Details:

Hospital Information

18.

Question - Not Required - Name of Hospital:

19.

Question - Not Required - Hospital Street Address:

20.

Question - Not Required - Hospital Phone #:

21.

Question - Not Required - Name of Physician:

22.

Question - Not Required - Date of Visit:

Month

Day

Year

Animal Owner Information

23.

Question - Not Required - Name:

24.

Question - Not Required - ADDRESS:

25.

Question - Not Required - Apt #

26.

Question - Not Required - CITY:

*27.

Question - Required - STATE: CA

*28.

Question - Required - ZIP:

29.

Question - Not Required - TELEPHONE OF DOG OWNER:

Animal Description Information

30.

Question - Not Required - Type of Animal:

31.

Question - Not Required - Breed of Animal:

32.

Question - Not Required - Sex of Animal: Male
Female

33.

Question - Not Required - Animal Name:

34.

Question - Not Required - Animal Color:

35.

Question - Not Required - Animal Age:

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First Name Last Name Email Address Please leave this field empty

SAN DIEGO CAMPUS

5500 Gaines St. (Adoptions)

5480 Gaines St. (Admissions)

San Diego, CA 92110

619-299-7012
ESCONDIDO CAMPUS

3500 Burnet Drive

Escondido, CA 92027

619-299-7012
OCEANSIDE CAMPUS

2905 San Luis Rey Road (Dogs)

572 Airport Road (Cats, Small Animals)

Oceanside, CA 92058

619-299-7012
PAWS SAN DIEGO

5480 Gaines St.

San Diego, CA 92110

619-299-7012, ext. 2100
PROJECT WILDLIFE

5433 Gaines St.

San Diego, CA 92110

619-299-7012

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