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Animal Bite Exposure Report
Complete this form to report when an animal bite has occurred. If you prefer, call (419) 599-5545 to report this. Provide as much information as you have and then press the submit button.
Information provided by*
First Name Last Name
Phone Number
- Area Code Phone Number
Date of Bite*
- Month - Day Year
Person Bitten (Victim)*
First Name Last Name
Age
Bite wound location
Victim's Parent or Guardian
First Name Last Name

Victim's Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Victim's Phone Number
- Area Code Phone Number
Did victim receive medical treatment?

Yes No
Hospital / Physician

Animal Owned?

Yes No
Animal Owner
First Name Last Name
Owner Phone
- Area Code Phone Number

Owner Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Type of Animal*
Animal Name
Mixed Breed?

Yes No
Dog Breed
Animal Color
Animal Immunized at the time of the bite?

Yes No Unknown
Date of Rabies Vaccination
- Month - Day Year
Veterinarian
Place where animal is confined
Briefly describe the circumstances of the bite*
Should be Empty: