Dog bite questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1CityState / Province / RegionPostal CodePhone *Email *Situation/Context *What happened before, during and after the bite?Information on the person that the bite was delivered to. *Please state whether adult or child. If child what is their age?Was the bite given to a known person or a stranger? *Please describe the relationship to you if applicableAdditional information *(E.g. regarding clothing – hi vis, hats, equipment- walking sticks, pushchair, broom etc.) Information on the animal delivered the biteSpecies/breed (please provide description – colour, size, etc.) Additional removed? were Age *Male *Neutered/in tact or N/AFemale *Spayed/unspayed or N/AKnown or unknown *If you know the dog, what is its relationship to you?Provide any relevant additional information *(e.g. other animal wearing a coat, muzzle, other equipment) Where did the incident occur? *Inside or outdoors?Specify which room *Were there any potential resources/triggers?Specify and describe location *Any potential resources/triggers?Where EXACTLY was the dog at the time of the incident? *When did the incident occur? *DaytimeNight timeLight or dark? *What were the conditions like?What was the dog going at the time? Sleeping?Eating?Playing?On a walk?Were any other people present when the incident occurred? *Were they known to you and the dog or unknown?Were any other animals present? *Define species and breed known or unknownWhere were they in relation to the dog? *What were they doing leading up to/just prior to the incident? *Please also state how they reactedWhat did the dog/animal that was bitten do immediately after? *What did the other people/animals do immediately after? *After the incident – people related. Did the person require medical attention? Was it straight away or later? *What treatment was required? (Stitches – how many? Antibiotics?) *After the incident – dog related. What did the dog do immediately after? *Was the dog removed from the situation? *If so, how?Was the dog reprimanded *After the incident – other dog or animal related. Did the dog/or animal require veterinary treatment?What treatment was required? Stitches – how many? Antibiotics?What expenses were accrued? *Were any other injuries sustained? *My dogMeOther dog’s ownerSomeone elseOtherIf other, please give detailsHad there been any similar incidences perviously? *BiteSnapGrowlOtherIf other, please give details?Who was involved/present? Was the location the same or different?More detailsWhat time of day/night was it? What were light conditions like? Time span over which multiple incidences occurred. Was it a specific event?Had any action been taken to manage/avoid further issues? *Nature of the bite?Single bite or multiple? If multiple, how many?Where on the body is/are the bite(s) located? *Did the dog bite and release immediately, or did the dog bite and hold on before releasing.? *If the dog did not release immediately how long did it take before the dog released? *Did the dog release by itself? *YesNoDid the dog have to be encouraged to let go? *YesNoDid the dog need to be physically removed? *YesNoDid the dog shake/rag whilst biting? *YesNoDid the bite leave any marks on the skin? *Please describe the marks. Where specifically? How many? *How big? *Colour and type of mark? *Did the bite leave puncture wounds?If so, where, how many, how deep? Was blood drawn?Did the dog bite through any clothing? *What was the clothing? How padded was the clothing and how much protection did it offer, if any?Please add photos of the injuries Click or drag files to this area to upload. You can upload up to 20 files. Additional notesPlease give as much information and as honestly as you can. We are here to help you if we can and withholding information helps us to assess what help, if any we can give to your dog. The image on the next page can help you decide the level of the injury sustained. We will not take responsibility for the rehoming of the dog until the Owner Relinquish form has been signed Submit
