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Animal Bite Reporting Survey

Report an Animal Bite in Dane County, Wisconsin

1. Date bite occurred *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Time bite occurred

Time of day

3. Full name of person who was bitten *This question is required.

	Last name
	First name

4. Date of birth of person who was bitten (if unknown, leave blank) This question requires a valid date format of MM/DD/YYYY.

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5. If under 18, parent/guardian name (if over 18, leave blank)

6. Phone number of person who was bitten (with area code)

Home/personal
Work

7. Address of person bitten (This form is for reporting bites in Dane County, Wisconsin only)

	Street address
	City
	State
	Zip code

8. Municipality where bite occurred (This form is for reporting bites in Dane County, Wisconsin only) *This question is required.

9. If you selected "Other" for the question above, please enter your municipality below.
(This form is for reporting bites in Dane County, Wisconsin only)

10. Bite wound description: *This question is required.

11. Animal description and name (if applicable): *This question is required.

12. Animal owned by _______ *This question is required.

Name of animal owner

	Last name
	First name

Date of birth of animal owner (if unknown, leave blank) This question requires a valid date format of MM/DD/YYYY.

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Phone number of animal owner (with area code)

	Personal/Home
	Work

Address of animal owner

	Street address
	City
	State
	Zip code

13. What kind of animal caused the bite? *This question is required.

Please enter an 'other' value for this selection.

14. Who is reporting this bite incident? Choose what best applies: *This question is required.

Please enter an 'other' value for this selection.

Name of clinic *This question is required.

Name of medical/veterinary provider reporting incident *This question is required.

Animal location

Expected release date of animal, or date released to owner (if unknown, leave blank) This question requires a valid date format of MM/DD/YYYY.

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Was the animal euthanized or did the animal die?

Date animal was euthanized or died (if unknown, leave blank) This question requires a valid date format of MM/DD/YYYY.

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What is the physician's information of the person bitten? (this is required for rabies testing)

	Physician name
	Physician phone number
	Name of clinic
	Clinic address

15. Are there any other comments or information you'd like to provide?