Veterinary Public Health Services

Animal Bite Report Form

Section 11.03 of NYC Health Code requires all animals bites to be reported within 24 hours of the event. All personal information submitted on this form will be held in strict confidence.

Form VPHS 55 - EGP

  

General Information:
Date of Bite	JanFebMarAprMayJunJulAugSepOctNovDec 01020304050607080910111213141516171819202122232425262728293031 200920102011201220132014201520162017201820192020
Animal	SelectDogCatRatBatOther
if other, specify
Animal Ownership	SelectOwnedUnownedNot Certain
Animal's Breed	SelectAirdaleAkitaBeagleBichon FriseBoxerBritany SpanielBulldogCat - Domestic Long HairCat - Domestic Short HairCat - HimalayanCat - OtherCat - SiameseChihuahuaChowCocker SpanielCollieCorgiDalmationDaschoundDobermanGreat DaneGreyhoundHoundHuskyJack RusselJindoKeeshLabradorLhaso ApsoMalamuteMalteeseMastiffMin. PincherMixed Breed DogNew FoundlandOtherPekePekingesePersianPitbullPointerPomeranianPoodlePugRetrieverRidgebackRottweilerRidgebackRottweilerSamoyedSchnauzerSetterSharpeiSheep DogSheperdShihtzuSib HuskeySpitzSpringerSt. BernardTerrier - OtherUnknownWeimaranerYorkshire Terrier
Color(s)

Person Bitten Information:
Last Name
First Name
Sex	M F
Age
Address
Apt #
Boro/City
State
Zip Code
Telephone Number
Area of Body Bitten	SelectArmBackHandFace, Head    LegStomach
Other
Patient's Activity at Time of Bite
Place of Occurrence (Include Boro)

Person Reporting Information
Last Name
First Name
Has the person bitten obtained medical treatment?	Yes No
Are you the person bitten?	Yes No
Relationship to person	SelectAuntBrotherBrother-in-lawClinic/HospDaughterFatherFather-in-lawFriendGrandfatherGrandmotherHusbandLawyerMedical ProviderMotherMother-in-lawNeighborOtherSchool NurseSisterSister-in-lawSonSupervisorUncleVictimWife
Address
Apt #
Boro/City
State
Zip Code
Telephone Number

Animal Owner's Information:
Last Name
First Name
Telephone Number
Address
Apt #
Boro/City
State
Zip Code
For Office Use Only
Case No.

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