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Veterinary Public Health Services : NYC DOHMH

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
Animal
if other, specify
Animal Ownership
Animal's Breed
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
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
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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