Bite/Scratch
Incident Details
Date of Bite/Scratch
Date Reported to Service Supervisor
Bite
Scratch
N/A
Was This a
Txt_AnimalLocationDuringIncident
Location of Animal during Incident
Multi_DescriptionOfIncident
Brief Description of Incident
(Include Location Bitten and/Or Scratched)
Person Bitten/Scratched
Name
Txt_PersonBittenScratchedName
Address
Txt_PersonBittenScratchedAddress
ZIP
Txt_PersonBittenScratchedZIP
Phone
Txt_PersonBittenScratchedPhone
City
Txt_PersonBittenScratchedCity
Alt. Ph.
Txt_PersonBittenScratchedAltPhone
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Selection
Staff
Student
Other
Animal Information
Name/ID #
Txt_AnimalNameID
Medical Record #
Txt_AnimalMedicalRecordNum
N/A
Color
Txt_AnimalColor
Yes
No
University-Owned
Female
Male
Sex
Species
Dog
Cat
Horse
Primate
Other
Selection
Txt_AnimalSpeciesOther
Other
Breed
Txt_AnimalBreed
Yes
No
Unknown
Rabies Vaccine
Date Vaccinated
Department
Small Animal
Large Animal
Selection
Owner
Med. Record
Confirmed By
Animal Sent Home
Yes
No
Animal Euthanized/Died
Yes
No
Date Animal Discharged from VMTH Care
Date Animal Euthanized/Died
Yes
No
Rabies Testing
Owner/Responsible Party Information
Yes
No
Is Owner/Resp. Party Known
Name
Txt_OwnerName
Address
Txt_OwnerAddress
City
Txt_OwnerCity
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Selection
ZIP
Txt_OwnerZIP
Phone
Txt_OwnerPhone
Alternate Ph.
Txt_OwnerAltPhone
Action Items
Veterinarian on Case Notified
N/A
VMACS and Paper Medical Record Flagged with Quarantine Info
N/A
Quarantine Sign Posted on Cage/Stall
Send completed form:
Student Health (Fax: 530-752-5587)
Yolo County animalcomplaint@yolocounty.gov
Contact Person
Name
Txt_ContactName
Txt_ContactPhonePrimary
Primary Phone
Secondary Phone
Txt_ContactPhoneSecondary
Txt_ContactEmail
Contact Email
VMTH BITE/SCRATCH REPORT
Submit
Animal Still in VMTH
Action Items Done
TxtIncidentTypeComputed
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