State Form 14072 - Official Indiana Animal Bites Report

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Official Indiana Animal Bites Report

Indiana State Department of Health

Sta te Form 14072 (R3/4-04)

Reporting Agency Case Number

Incident Location Address

Reported by (name)

Reporting Agency

Bite Classification

Reported by (phone)

(see reverse side of this page to classify)

County

Incident

Off

Property

Received by (name)

Exposure Date

Victim Type (circle 2)

Human

Animal

Juvenile

Adult

Release Date

Reported Date

Reported Time

VICTIM INFORMATION

OWNER INFORMATION

Person bitten

(if animal victim, use this space for animal victim's owner):

Owner of Animal:

Last

First

Mid.

Date of Birth

Last Name

Sex

Street Address

City

Zip

Home Telephone

Work Telephone

First Name

Sex

Color/Markings

Name

Sex

Biting Animal

Date of Birth

Dog

Cat

Other

Street Address

City

Zip

Telephone

Neutered

Home:

Breed

Work:

Animal's Veterinarian

Prior Incidents

Parent if victim is a juvenile:

Last

First

Mid.

Rabies Vaccine

Date

Street Address

City

Zip

Telephone

License Number

Microchip Number

Citation issued?

Home:

Rabies Tag Number

Work:

If animal victim:

Location of Quarantine

Breed/Species

Color/Markings

Vaccine Date (rabies)

Name

Date of Quarantine

Quarantined by (name)

Release Date

Sex

Time of bite

Released from Quarantine by (name):

(if animal victim)

Treating Physician (or veterinarian)

Quarantined?

Name:

Owner release card (date received):

Yes

Telephone:

Released from shelter quarantine (date):

Location on Body and Extent of Injury:

Lab #/Result:

Victim's statement of incident (animal owner if animal victim):

Animal owner's statement of incident:

State Department of Health required information (must be completed):

Circumstances:

Species (fill in the correct biting species):

Animal confined (indoors, penned, tethered, or on leash)

Bat

Dog

Hamster

Raccoon

Animal not confined (stray, roaming, etc.)

Cattle

Ferret

Horse

Rat

Wild Animal

Unprovoked

Provoked

Cat

Fox

Mouse

Squirrel

Unknown

Other

Chipmunk

Gerbil

Rabbit

Other

Action taken with animal:

No Action

Body destroyed

If Other, specify

Escaped/not found

Head sent to ISDH Lab

Did the animal exhibit any of the following:

Pet quarantined (see dates above)

Other

Convulsions

Aggression

Inability to eat/drink

(dog, cat, ferret only)

Unknown

Excessive salivation

Paralysis

Depression

I, the undersigned, have received a copy of the quarantine guidelines, have read them, and understand them. I agree to comply with all provisions of the quarantine

guidelines and understand that noncompliance may result in seizure of my pet if it is in home quarantine or loss of my pet if it is not properly claimed at the end of the

quarantine period from the quarantining agency.

Witness___________________________________

Date __________________

Signature__________________________________________

DISTRIBUTION: White - Enforcing Agency, Canary - Local Health Department, Pink - Owner