{"id":312506,"date":"2023-05-17T13:20:00","date_gmt":"2023-05-17T20:20:00","guid":{"rendered":"http:\/\/animalservices.venturacounty.gov\/?page_id=312506"},"modified":"2026-02-12T17:21:05","modified_gmt":"2026-02-13T00:21:05","slug":"animal-bite-reporting","status":"publish","type":"page","link":"https:\/\/animalservices.venturacounty.gov\/vi\/animal-bite-reporting\/","title":{"rendered":"Animal Bite Reporting Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"312506\" class=\"elementor elementor-312506\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5a737f4 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5a737f4\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-305ad17\" data-id=\"305ad17\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6aed2d1 elementor-widget elementor-widget-text-editor\" data-id=\"6aed2d1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"color: #007fff;\"><strong>***FOR MEDICAL PROFESSIONAL USE <span style=\"text-decoration: underline;\">ONLY<\/span>. ***<\/strong><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-94d3a68 elementor-widget elementor-widget-text-editor\" data-id=\"94d3a68\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span><strong><span style=\"color: #f20000;\">NOTE: \u00a0<\/span><\/strong><span style=\"color: #f20000;\">Due to <\/span><span style=\"color: #f20000;\"><span style=\"caret-color: #f20000;\">unforeseen<\/span>\u00a0technical issues, animal bite reports submitted between <strong><span style=\"text-decoration: underline; color: #000000;\">January 15 &#8211; February 11th<\/span><\/strong>, may not have been received by our department. If you did not receive an email conformation, please resubmit as soon as possible. \u00a0We apologize for the inconvenience.<\/span><\/span><\/p><p>This form to be used by <span style=\"color: #0079f2;\"><strong>MEDICAL PROFESSIONALS ONLY<\/strong><\/span>\u00a0to report animal bites to humans.\u00a0 Reports filed by non-medical personnel will not be processed.\u00a0 If you are a <strong>non-medical professional<\/strong> who would like to report an animal bite, please call <strong>(805) 388-4341<\/strong>.<\/p><p>Whenever a patient is treated for <u>any<\/u> animal bite, an Animal Bite Record <u>must<\/u> be completed pursuant to Title 17, Section 2606 of the California Code of Regulations.\u00a0 It is the medical care provider&#8217;s responsibility to see that all required portions of this report are completed to the best of the patient\u2019s and medical professional&#8217;s ability, and <span style=\"text-decoration: underline;\">immediately<\/span> submit this form to Ventura County Animal Services.<\/p><p>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 &#8220;Bite Report.&#8221;\u00a0 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.\u00a0 \u00a0Thank you.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t<div class=\"elementor-element elementor-element-a4e356d e-flex e-con-boxed e-con e-parent\" data-id=\"a4e356d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a67e589 elementor-widget elementor-widget-shortcode\" data-id=\"a67e589\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_12' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Animal Bite Reporting Form<\/h2>\n                            <p class='gform_description'>This is an online form where Medical Professionals can report a bite incident to a human.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/vi\/wp-json\/wp\/v2\/pages\/312506' data-formid='12' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Lf7QbYrAAAAAKcQPdQmWu4270fzpeXdgYeK50tg' data-tabindex='0'><input id=\"input_1f22592cf5125f9bc5fbc5763e3be876\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_1f22592cf5125f9bc5fbc5763e3be876\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_12_78\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_78'>Facebook<\/label><div class='gfield_description' id='gfield_description_12_78'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_78' id='input_12_78' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_12_34\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_34'>Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_34' id='input_12_34' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_34_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_12_34_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_34' class='gform_hidden' value='https:\/\/animalservices.venturacounty.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_12_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_35'>Date Bite Occurred<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_12_35' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_35_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_12_35_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_35' class='gform_hidden' value='https:\/\/animalservices.venturacounty.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_12_36\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of Attending Physician<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_36'>\n                            \n                            <span id='input_12_36_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_36.3' id='input_12_36_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_36_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_36_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_36.6' id='input_12_36_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_36_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">MEDICAL CARE PROVIDER INFORMATION<\/h3><\/div><fieldset id=\"field_12_37\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_37'>\n                            \n                            <span id='input_12_37_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_37.3' id='input_12_37_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_37_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_37_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_37.6' id='input_12_37_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_37_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_38\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_38'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_12_38' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_39\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_39'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_39' id='input_12_39' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_12_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">VICTIM&#039;S INFORMATION<\/h3><\/div><fieldset id=\"field_12_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_5'>\n                            \n                            <span id='input_12_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_12_5_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_12_5_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_12_6\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Home Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_6'>(Please include apartment number if applicable.)<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_12_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_12_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_12_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_12_6_1' id='input_12_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_12_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_12_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_12_6_2' id='input_12_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_12_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_12_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_12_6_3' id='input_12_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_12_6_4_container' >\n                                        <select name='input_6.4' id='input_12_6_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' selected='selected'>California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_12_6_4' id='input_12_6_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_12_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_12_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_12_6_5' id='input_12_6_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_12_6_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_12_41\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_41'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_12_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_12_41_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_12_41_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_12_41' class='gform_hidden' value='https:\/\/animalservices.venturacounty.gov\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_12_42\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_42'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_42' id='input_12_42' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_12_44\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_44'>Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_44' id='input_12_44' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_43\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_43'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_43' id='input_12_43' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_45\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_45'>Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_45' id='input_12_45' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_12_46\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If victim is a minor, indicate parent\/guardian&#039;s name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_46'>\n                            \n                            <span id='input_12_46_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_46.3' id='input_12_46_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_46_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_46_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_46.6' id='input_12_46_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_46_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">ABOUT THE BITE<\/h3><\/div><div id=\"field_12_50\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_50'>City where bite occurred<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_12_50' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Camarillo' >Camarillo<\/option><option value='Fillmore' >Fillmore<\/option><option value='Moorpark' >Moorpark<\/option><option value='Ojai' >Ojai<\/option><option value='Oxnard' >Oxnard<\/option><option value='Port Hueneme' >Port Hueneme<\/option><option value='Santa Paula' >Santa Paula<\/option><option value='Simi Valley' >Simi Valley<\/option><option value='Ventura' >Ventura<\/option><option value='Unincorporated Ventura County' >Unincorporated Ventura County<\/option><\/select><\/div><\/div><div id=\"field_12_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_77'>Type of location bite occurred.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_77'>(Home, park, sidewalk, etc.)<\/div><div class='ginput_container ginput_container_text'><input name='input_77' id='input_12_77' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_77\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_48'>Victim description of catalyst for the bite incident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_48'>What triggered the bite?  Provide a detailed explanation of instances that led to the bite.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_12_48' class='textarea large'  aria-describedby=\"gfield_description_12_48\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_51\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_51'>Any additional information you would like to add:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_12_51' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Location(s) of bite:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_52'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_52'><div class='gchoice gchoice_12_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Face (head, neck, lip, etc.)'  id='choice_12_52_1'   aria-describedby=\"gfield_description_12_52\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_12_52_1' id='label_12_52_1' class='gform-field-label gform-field-label--type-inline'>Face (head, neck, lip, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Arm (shoulder, elbow, etc.)'  id='choice_12_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_52_2' id='label_12_52_2' class='gform-field-label gform-field-label--type-inline'>Arm (shoulder, elbow, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='Hand (wrist, palm, fingers, etc.)'  id='choice_12_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_52_3' id='label_12_52_3' class='gform-field-label gform-field-label--type-inline'>Hand (wrist, palm, fingers, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_52_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.4' type='checkbox'  value='Torso (stomach, back, etc.)'  id='choice_12_52_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_52_4' id='label_12_52_4' class='gform-field-label gform-field-label--type-inline'>Torso (stomach, back, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_52_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.5' type='checkbox'  value='Pelvic region (buttocks, hips, etc.)'  id='choice_12_52_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_52_5' id='label_12_52_5' class='gform-field-label gform-field-label--type-inline'>Pelvic region (buttocks, hips, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_52_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.6' type='checkbox'  value='Leg (knee, thigh, etc.)'  id='choice_12_52_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_52_6' id='label_12_52_6' class='gform-field-label gform-field-label--type-inline'>Leg (knee, thigh, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_52_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.7' type='checkbox'  value='Foot (ankle, knee, toes, etc.)'  id='choice_12_52_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_52_7' id='label_12_52_7' class='gform-field-label gform-field-label--type-inline'>Foot (ankle, knee, toes, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_52_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.8' type='checkbox'  value='Unknown Location'  id='choice_12_52_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_52_8' id='label_12_52_8' class='gform-field-label gform-field-label--type-inline'>Unknown Location<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which side of the body is the bite located?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_53'>\n\t\t\t<div class='gchoice gchoice_12_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Left'  id='choice_12_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_53_0' id='label_12_53_0' class='gform-field-label gform-field-label--type-inline'>Left<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Right'  id='choice_12_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_53_1' id='label_12_53_1' class='gform-field-label gform-field-label--type-inline'>Right<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Both'  id='choice_12_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_53_2' id='label_12_53_2' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_53_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Unknown'  id='choice_12_53_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_53_3' id='label_12_53_3' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_68\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_68'>Photo(s) of bite wound.<\/label><div class='gfield_description' id='gfield_description_12_68'>DO NOT upload images of medical records.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='524288000' \/><input name='input_68' id='input_12_68' type='file' class='large' aria-describedby=\"gfield_upload_rules_12_68 gfield_description_12_68\" onchange='javascript:gformValidateFileSize( this, 524288000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_12_68'>Max. file size: 500 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_12_68'><\/div> <\/div><\/div><div id=\"field_12_75\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_75'>Photo(s) of bite wound.<\/label><div class='gfield_description' id='gfield_description_12_75'>DO NOT upload images of medical records.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='524288000' \/><input name='input_75' id='input_12_75' type='file' class='large' aria-describedby=\"gfield_upload_rules_12_75 gfield_description_12_75\" onchange='javascript:gformValidateFileSize( this, 524288000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_12_75'>Max. file size: 500 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_12_75'><\/div> <\/div><\/div><div id=\"field_12_74\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_74'>Photo(s) of bite wound.<\/label><div class='gfield_description' id='gfield_description_12_74'>DO NOT upload images of medical records.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='524288000' \/><input name='input_74' id='input_12_74' type='file' class='large' aria-describedby=\"gfield_upload_rules_12_74 gfield_description_12_74\" onchange='javascript:gformValidateFileSize( this, 524288000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_12_74'>Max. file size: 500 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_12_74'><\/div> <\/div><\/div><div id=\"field_12_73\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_73'>Photo(s) of bite wound.<\/label><div class='gfield_description' id='gfield_description_12_73'>DO NOT upload images of medical records.<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='524288000' \/><input name='input_73' id='input_12_73' type='file' class='large' aria-describedby=\"gfield_upload_rules_12_73 gfield_description_12_73\" onchange='javascript:gformValidateFileSize( this, 524288000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_12_73'>Max. file size: 500 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_12_73'><\/div> <\/div><\/div><div id=\"field_12_55\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">ABOUT THE ANIMAL<\/h3><\/div><div id=\"field_12_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_54'>Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_54'>(Dog, cat, etc.)<\/div><div class='ginput_container ginput_container_text'><input name='input_54' id='input_12_54' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_54\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_59'>Animal&#039;s Name<\/label><div class='gfield_description' id='gfield_description_12_59'>(If known.)<\/div><div class='ginput_container ginput_container_text'><input name='input_59' id='input_12_59' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_59\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_58\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_58'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_58'>(Best guess.)<\/div><div class='ginput_container ginput_container_number'><input name='input_58' id='input_12_58' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_12_58\" \/><\/div><\/div><div id=\"field_12_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_57'>Breed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_57'>If mix, list all breeds.<\/div><div class='ginput_container ginput_container_text'><input name='input_57' id='input_12_57' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_57\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_56'>Color(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_56'>If multiple, list colors.<\/div><div class='ginput_container ginput_container_text'><input name='input_56' id='input_12_56' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_56\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_61'>\n\t\t\t<div class='gchoice gchoice_12_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Male'  id='choice_12_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_61_0' id='label_12_61_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Neutered Male'  id='choice_12_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_61_1' id='label_12_61_1' class='gform-field-label gform-field-label--type-inline'>Neutered Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Female'  id='choice_12_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_61_2' id='label_12_61_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_61_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Spayed Female'  id='choice_12_61_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_61_3' id='label_12_61_3' class='gform-field-label gform-field-label--type-inline'>Spayed Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_61_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Unknown'  id='choice_12_61_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_61_4' id='label_12_61_4' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Circumstance of the bite.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_72'>\n\t\t\t<div class='gchoice gchoice_12_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='APPROACHING:  Dog was being approached by the victim.'  id='choice_12_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_0' id='label_12_72_0' class='gform-field-label gform-field-label--type-inline'>APPROACHING:  Dog was being approached by the victim.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='BODY HANDLING:  Dog was being touched or handled by the victim.'  id='choice_12_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_1' id='label_12_72_1' class='gform-field-label gform-field-label--type-inline'>BODY HANDLING:  Dog was being touched or handled by the victim.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='CHAINED\/TIED:  Dog was chained and\/or tied up.'  id='choice_12_72_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_2' id='label_12_72_2' class='gform-field-label gform-field-label--type-inline'>CHAINED\/TIED:  Dog was chained and\/or tied up.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='COLLAR:  Dog was grabbed or being led by collar.'  id='choice_12_72_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_3' id='label_12_72_3' class='gform-field-label gform-field-label--type-inline'>COLLAR:  Dog was grabbed or being led by collar.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='DELIVERY:  Dog bit a delivery, service, or maintenance person.'  id='choice_12_72_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_4' id='label_12_72_4' class='gform-field-label gform-field-label--type-inline'>DELIVERY:  Dog bit a delivery, service, or maintenance person.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='DOG FIGHT:  Dog was involved in a dog (animal) fight.'  id='choice_12_72_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_5' id='label_12_72_5' class='gform-field-label gform-field-label--type-inline'>DOG FIGHT:  Dog was involved in a dog (animal) fight.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='EATING:  Dog was eating from a bowl.'  id='choice_12_72_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_6' id='label_12_72_6' class='gform-field-label gform-field-label--type-inline'>EATING:  Dog was eating from a bowl.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='FENCE:  Dog bit a person reaching through, under, or over a fence.'  id='choice_12_72_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_7' id='label_12_72_7' class='gform-field-label gform-field-label--type-inline'>FENCE:  Dog bit a person reaching through, under, or over a fence.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='GRABBED:  Dog was grabbed by the victim.'  id='choice_12_72_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_8' id='label_12_72_8' class='gform-field-label gform-field-label--type-inline'>GRABBED:  Dog was grabbed by the victim.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='INJURED:  Dog was reportedly injured or in pain.'  id='choice_12_72_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_9' id='label_12_72_9' class='gform-field-label gform-field-label--type-inline'>INJURED:  Dog was reportedly injured or in pain.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='LEASHED:  Dog was leashed.'  id='choice_12_72_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_10' id='label_12_72_10' class='gform-field-label gform-field-label--type-inline'>LEASHED:  Dog was leashed.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='MOTHER: Dog was with her puppy\/puppies.'  id='choice_12_72_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_11' id='label_12_72_11' class='gform-field-label gform-field-label--type-inline'>MOTHER: Dog was with her puppy\/puppies.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='OWNER:  Dog was guarding or protecting their owner.'  id='choice_12_72_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_12' id='label_12_72_12' class='gform-field-label gform-field-label--type-inline'>OWNER:  Dog was guarding or protecting their owner.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_13'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='PETTING:  Dog was being petted.'  id='choice_12_72_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_13' id='label_12_72_13' class='gform-field-label gform-field-label--type-inline'>PETTING:  Dog was being petted.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_14'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='PLAY:  Dog was playing with the injured party.'  id='choice_12_72_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_14' id='label_12_72_14' class='gform-field-label gform-field-label--type-inline'>PLAY:  Dog was playing with the injured party.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_15'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='R.A.L.:  Dog was Running At Large.'  id='choice_12_72_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_15' id='label_12_72_15' class='gform-field-label gform-field-label--type-inline'>R.A.L.:  Dog was Running At Large.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_16'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='RESOURCE GUARDING:  Dog was guarding an item of value (i.e. toy).'  id='choice_12_72_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_16' id='label_12_72_16' class='gform-field-label gform-field-label--type-inline'>RESOURCE GUARDING:  Dog was guarding an item of value (i.e. toy).<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_17'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='RESTING:  Dog was disturbed while resting\/sleeping.'  id='choice_12_72_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_17' id='label_12_72_17' class='gform-field-label gform-field-label--type-inline'>RESTING:  Dog was disturbed while resting\/sleeping.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_18'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='TEASING:  Dog was being teased by the victim.'  id='choice_12_72_18' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_18' id='label_12_72_18' class='gform-field-label gform-field-label--type-inline'>TEASING:  Dog was being teased by the victim.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_19'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='VET\/GROOM:  Dog was at a veterinary hospital, clinic, or grooming facility.'  id='choice_12_72_19' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_19' id='label_12_72_19' class='gform-field-label gform-field-label--type-inline'>VET\/GROOM:  Dog was at a veterinary hospital, clinic, or grooming facility.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_20'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='VISITING:  The victim was visiting the home or property of the dog&#039;s owner.'  id='choice_12_72_20' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_20' id='label_12_72_20' class='gform-field-label gform-field-label--type-inline'>VISITING:  The victim was visiting the home or property of the dog's owner.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_72_21'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='UNKNOWN:  Dog was in an unknown situation.'  id='choice_12_72_21' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_72_21' id='label_12_72_21' class='gform-field-label gform-field-label--type-inline'>UNKNOWN:  Dog was in an unknown situation.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Which best describes the bite injury?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_76'>\n\t\t\t<div class='gchoice gchoice_12_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='LEVEL 1:  Aggressive behavior but no skin-break by teeth.'  id='choice_12_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_76_0' id='label_12_76_0' class='gform-field-label gform-field-label--type-inline'>LEVEL 1:  Aggressive behavior but no skin-break by teeth.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='LEVEL 2:  Skin-break by teeth but no vertical puncture.  May have surface abrasions or lacerations.'  id='choice_12_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_76_1' id='label_12_76_1' class='gform-field-label gform-field-label--type-inline'>LEVEL 2:  Skin-break by teeth but no vertical puncture.  May have surface abrasions or lacerations.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_76_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='LEVEL 3:  1-4 punctures from single bite with no puncture deeper than half the length of the dog&#039;s canine teeth.  There may be lacerations in a single direction.'  id='choice_12_76_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_76_2' id='label_12_76_2' class='gform-field-label gform-field-label--type-inline'>LEVEL 3:  1-4 punctures from single bite with no puncture deeper than half the length of the dog's canine teeth.  There may be lacerations in a single direction.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_76_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='LEVEL 4:  1-4 punctures from a single bite with at least one puncture deeper than half the length of the dog&#039;s canine teeth.  May also have deep bruising around the wound (i.e. dog held on for ___ seconds and bro down) or lacerations in both directions (i.e. dog held on and shook their head from side to side).'  id='choice_12_76_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_76_3' id='label_12_76_3' class='gform-field-label gform-field-label--type-inline'>LEVEL 4:  1-4 punctures from a single bite with at least one puncture deeper than half the length of the dog's canine teeth.  May also have deep bruising around the wound (i.e. dog held on for ___ seconds and bro down) or lacerations in both directions (i.e. dog held on and shook their head from side to side).<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_76_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='LEVEL 5:  Multiple-bite incident with at least two 92) LEVEL 4 bites or multiple-attack incidents with at least one (1) LEVEL 4 bite in each.'  id='choice_12_76_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_76_4' id='label_12_76_4' class='gform-field-label gform-field-label--type-inline'>LEVEL 5:  Multiple-bite incident with at least two 92) LEVEL 4 bites or multiple-attack incidents with at least one (1) LEVEL 4 bite in each.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_76_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='LEVEL 6:  Victim deceased.'  id='choice_12_76_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_76_5' id='label_12_76_5' class='gform-field-label gform-field-label--type-inline'>LEVEL 6:  Victim deceased.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_76_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='UNKNOWN:  Unknown bite severity due to lack of information.'  id='choice_12_76_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_76_6' id='label_12_76_6' class='gform-field-label gform-field-label--type-inline'>UNKNOWN:  Unknown bite severity due to lack of information.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_62\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">ANIMAL OWNER&#039;S INFORMATION<\/h3><\/div><fieldset id=\"field_12_63\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_63'>\n                            \n                            <span id='input_12_63_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_63.3' id='input_12_63_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_63_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_63_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_63.6' id='input_12_63_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_63_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_12_64\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_12_64' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_12_64_1_container' >\n                                        <input type='text' name='input_64.1' id='input_12_64_1' value=''    aria-required='false'    \/>\n                                        <label for='input_12_64_1' id='input_12_64_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_12_64_2_container' >\n                                        <input type='text' name='input_64.2' id='input_12_64_2' value=''     aria-required='false'   \/>\n                                        <label for='input_12_64_2' id='input_12_64_2_label' 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