Nassau County Department of Health

Animal Bite Report

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Information on Person Bitten

First Name:*

Last Name:*

Date of Birth:

Phone Number: *

Address Search:

Street Address: *

City: *

State: *

Zip Code:*

Incident Information

Location of Incident:

City:

Zip Code:

Circumstances of Bite:

Date of Bite: *

Time of Bite:

Wound Location:

Treated By:

Medical Treatment Provided?*

Reported By: *

Phone Number of Individual Reporting: *

Information on Animal and Owner

Ownership Status:*

Animal Owner's Name:

Owner's Street Address:

City:

State:

Zip Code:

Owner's Phone Number:

Type of Animal:*

Animal's Name:

Breed:

Colors:

Sex:

Age:

Expiration Date of Rabies Vaccination:

State in which given:

Tag #:

Comments:

I acknowledge and Consent as follows:

I am responsible for providing correct and accurate information on this Form, including full name, date of birth, email address, mailing address, and phone number and all responses on this form.
I acknowledge that commonly used e-mail services are not secure and fall outside the security requirement set forth by the Health Insurance Portability and Accountability Act (HIPAA) for transmission of protected information.
I agree to E-Mail/Electronic Communication Consent above

Email Address*(of person submitting the form)
I understand that pursuant to the Electronic Signatures and Records Act (ESRA), the use of an electronic signature shall have the same validity and effect as a signature by hand.

All fields marked with a red asterisk (*)are required