Nassau County Department of Health

Animal Bite Report

Information on Person Bitten
Incident Information
Information on Animal and Owner
I acknowledge and Consent as follows:
  1. 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.
  2. 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.
  3. 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