Revised January 2020 VICTIM INFORMATION Last Name: ___________________ First: ___________________________ Middle: ________________ DOB: ____/____/____ If child <18: Parent’s Last Name: ___________________________ First: ___________________________ Reported Age: ___________ □ Days □ Months □ Years Sex: □ Male □ Female □ Unknown Street Address: _____________________________________________________________________________________________ City: __________________________ County: ________________________ State: __________________ Zip: _______________ Home Phone: ________________________ Work: ___________________________ Cell: ________________________________ Type of Animal: _____________________________________ Check One: □ Domesc □ Stray □ Wild □ Unknown Descripon of Animal (Breed, Size, Color, Hair Length, etc.): ________________________________________________________ __________________________________________________________________________________________________________ Veterinarian: ___________________________ Phone: ________________________ Date of Last Rabies Shot: ____/____/____ Owner’s Name: _________________________________________________________ Street Address: _____________________________________________________________________________________________ City: __________________________ County: ________________________ State: __________________ Zip: _______________ Home Phone: ________________________ Work: ___________________________ Cell: ________________________________ Animal Bite Report ANIMAL INFORMATION Was the vicm aacked by surprise? □ Yes □ No □ Unknown Was the vicm aempng to touch, feed, or pick up animal? □ Yes □ No □ Unknown Was the aack provoked? □ Yes □ No □ Unknown Was another animal present? □ Yes □ No □ Unknown Did the animal appear normal/healthy? □ Yes □ No □ Unknown Notes: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ CIRCUMSTANCES OF INCIDENT Date of Bite: ____/_____/_____ Date Reported: ____/_____/_____ Reported by: _____________________________ Was the vicm bien? □ Yes □ No □ Unknown Was the vicm scratched? □ Yes □ No □ Unknown If yes: Part of the body bien/scratched: ______________________ Was the skin broken? □ Yes □ No □ Unknown Has the vicm received a tetanus vaccine? □ Yes □ No □ Unknown Has the vicm received anbiocs? □ Yes □ No □ Unknown Has the vicm ever received rabies vaccine? □ Yes □ No □ Unknown Is the vicm immunocompromised or taking immunosuppressive medicaons? □ Yes □ No □ Unknown Was rabies post-exposure prophylaxis iniated? □ Yes □ No □ Unknown If yes: Date iniated: ____/____/____ Notes: ____________________________________________________ Was HRIG given? □ Yes □ No □ Unknown If yes: Date given: ____/____/____ Notes: ____________________________________________________ MEDICAL INFORMATION

Animal ite Report - Tennessee...Animal ite Report. ANIMAL INFORMATION. Was the victim attacked by surprise? Notes: Yes No Unknown. Was the victim attempting to touch, feed, or pick

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Page 1: Animal ite Report - Tennessee...Animal ite Report. ANIMAL INFORMATION. Was the victim attacked by surprise? Notes: Yes No Unknown. Was the victim attempting to touch, feed, or pick

Revised January 2020

VICTIM INFORMATION

Last Name: ___________________ First: ___________________________ Middle: ________________ DOB: ____/____/____

If child <18: Parent’s Last Name: ___________________________ First: ___________________________

Reported Age: ___________ □ Days □ Months □ Years Sex: □ Male □ Female □ Unknown

Street Address: _____________________________________________________________________________________________

City: __________________________ County: ________________________ State: __________________ Zip: _______________

Home Phone: ________________________ Work: ___________________________ Cell: ________________________________

Type of Animal: _____________________________________ Check One: □ Domestic □ Stray □ Wild □ Unknown

Description of Animal (Breed, Size, Color, Hair Length, etc.): ________________________________________________________

__________________________________________________________________________________________________________

Veterinarian: ___________________________ Phone: ________________________ Date of Last Rabies Shot: ____/____/____

Owner’s Name: _________________________________________________________

Street Address: _____________________________________________________________________________________________

City: __________________________ County: ________________________ State: __________________ Zip: _______________

Home Phone: ________________________ Work: ___________________________ Cell: ________________________________

Animal Bite Report

ANIMAL INFORMATION

Was the victim attacked by surprise?

□ Yes □ No □ UnknownWas the victim attempting to touch, feed, or pick up animal?

□ Yes □ No □ UnknownWas the attack provoked?

□ Yes □ No □ UnknownWas another animal present?

□ Yes □ No □ UnknownDid the animal appear normal/healthy?

□ Yes □ No □ Unknown

Notes:

____________________________________________________

CIRCUMSTANCES OF INCIDENT

Date of Bite: ____/_____/_____ Date Reported: ____/_____/_____ Reported by: _____________________________

Was the victim bitten? □ Yes □ No □ Unknown Was the victim scratched? □ Yes □ No □ Unknown If yes: Part of the body bitten/scratched: ______________________ Was the skin broken? □ Yes □ No □ Unknown

Has the victim received a tetanus vaccine? □ Yes □ No □ Unknown

Has the victim received antibiotics? □ Yes □ No □ Unknown

Has the victim ever received rabies vaccine? □ Yes □ No □ Unknown

Is the victim immunocompromised or taking immunosuppressive medications? □ Yes □ No □ Unknown

Was rabies post-exposure prophylaxis initiated? □ Yes □ No □ UnknownIf yes: Date initiated: ____/____/____ Notes: ____________________________________________________

Was HRIG given? □ Yes □ No □ UnknownIf yes: Date given: ____/____/____ Notes: ____________________________________________________

MEDICAL INFORMATION