Animal Bite Reporting Form

***FOR MEDICAL PROFESSIONAL USE NUR. ***

This form to be used by MEDICAL PROFESSIONALS ONLY to report animal bites to humans. Reports filed by non-medical personnel will not be processed. If you are a non-medical professional who would like to report an animal bite, please call (805) 388-4341.

Whenever a patient is treated for any animal bite, an Animal Bite Record muss be completed pursuant to Title 17, Section 2606 of the California Code of Regulations. It is the medical care provider’s responsibility to see that all required portions of this report are completed to the best of the patient’s and medical professional’s ability, and immediately submit this form to Ventura County Animal Services.

For medical providers who wish to submit this form via FAX or email, print this page, complete the form using blue/black ink, and send via FAX to (805) 388-4393 or scan and send via email to info@vcas.us with subject “Bite Report.” Medical professionals who wish to keep a copy of this information for your records, print this page before clicking the submission button at the bottom. Thank you.

Today's Date

Date Bite Occurred

Attending Physician

Name of Medical Care Provider

Telephone Number of Medical Care Provider

Email Address of Medical Care Provider

Victim's FIRST NAME

Victim's LAST NAME

Victim's ADDRESS (include apartment number if applicable)

Stadt

Staat

Postleitzahl

Victim's Date of Birth

Victim's Age

Victim's Home Phone

Victim's Cell Phone

Victim's Email Address

If victim is a minor, indicate parent/guardian's name

Victim description of catalyst for bite incident.

City Where Bite Occurred (Select one)

Any additional information or details you would like to add:

Location of bite (Check all that apply):

Which side of the body is the bite located?

Left Right Both Unknown

Type of animal

Name of animal

Age of animal (best guess)

Breed (best guess)

Color(s)

Sex

Animal Owner's Last Name

Animal Owner's First name

Animal Owner's Address:

City:

State:

ZIP code:

Animal Owner's Home Phone

Animal Owner's Cell Number

Photo(s) of bite wound. (Please DO NOT send images of medical records.)

Which best describes the bite injury? (OPTIONAL)

LEVEL 1 Aggressive behavior but no skin-break by teeth. LEVEL 2 Skin-break by teeth but no vertical puncture. May have surface abrasions or laceration. LEVEL 3 1-4 punctures from a single bite with no puncture deeper than half the length of the dog's canine teeth. There may be lacerations in a single direction. LEVEL 4 1-4 punctures from a single bite with no at least one puncture deeper than half the length of the dog's canine teeth. May also have deep bruising around the wound (dog held on for ___ seconds and bore down) or lacerations in both directions (dog held on and shook their head from side to side). LEVEL 5 Multiple-bite incident with at least two (2) Level 4 bites or multiple-attack incident with at least one (1) Level 4 bite in each. LEVEL 6 Victim deceased. UNKNOWN Unknown bite severity due to lack of information, etc.

TIERHEIM CAMARILLO

Tierheim Simi Valley

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