City of Evansville / Vanderburgh County : Form/Survey

Survey/Form Review

Bite Report Form

VICTIM INFORMATION

1. Victim Name:

2. If victim is a minor, please list guardian name:

3. Address:

4. Phone:

5. Cell Phone:

6. Email:

7. Bite Location:

8. Time of Bite:

9. Date of Bite:

10. Other Details:

OWNER INFORMATION

11. Owner Name:

12. Owner Address:

13. Owner Phone:

14. Animal Type:

Dog

Cat

Other

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