Form Center

2. Date of Bite/Exposure*
   Date of Bite/Exposure

4. Biting/Scratching Animal Information
6. Name of Biting/Scratching Animal
7. Biting/Scratching Animal Ownership
   -- Select One --OwnedUnownedI Don't Know
9. Animal Species*
   -- Select One --CatDogBatOpossumRaccoonGround HogHorseOther
10. If other please state
12. Animal Breed
13. Animal Colors
15. Animal Age
16. Animal Sex
    -- Select One --FemaleMaleUnknown

18. Biting/Scratching Animal Owner's Information
20. Last Name*
21. First Name*
23. Phone Number
24. Email Address
26. Address
28. City
29. State
30. Zip

32. Human Victim Information - If not human enter N/A
34. Last Name*
35. First Name*
37. Victim's Sex at Birth

    1. Female

    1. Male
38. Victim's Date of Birth
    Victim's Date of Birth
40. Phone Number
41. Email Address
43. Address
45. City
46. State
47. Zip

49. Animal Victim Information - If not an animal enter N/A
51. Name of Animal Victim
53. Animal Species
54. Animal Breed
56. Animal Colors
57. Animal Sex
    -- Select One --FemaleMaleUnknown
59. Animal's Rabies Vaccination Record if Available
61. Veterinarian where rabies vaccine obtained
62. Rabies Vaccine Expiration Date
    Rabies Vaccine Expiration Date
64. Rabies Tag Number
65. Upload a Copy of Rabies Vaccination

67. Animal Victim Owner's Information
69. Last Name
70. First Name
72. Phone Number
73. Email Address
75. Address1
77. City
78. State
79. Zip

81. Person or Facility Reporting
83. Name*
84. Has the Victim Received Medical Care?

    1. Yes

    1. No
86. Are You the Bite/Scratch Victim?

    1. Yes

    1. No
88. Phone Number*
89. Email Address*
91. Address1
93. City
94. State
95. Zip
97. Description of Incident*
Leave This Blank:


99. 1. Receive an email copy of this form.
100. Email address

     This field is not part of the form submission.

101. Submit Submit and Print

* indicates a required field