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Official Indiana Animal Bites Report

Indiana State Department of Health

State Form 14072 (R3/4-04)

Reporting Agency Case Number

Victim

Incident & Circumstances Animal Parent

Incident Location Address

Reported by (name)

Reporting Agency

Bite Classification

Reported by (phone)

(see reverse side of this page to classify)

County

Incident

Off

Property

Received by (name)

Exposure Date

Victim Type (circle 2)

Human

Animal

Juvenile

Adult

Reported Date

Reported Time

Release Date

VICTIM INFORMATION

OWNER INFORMATION

Person bitten (if animal victim, use this space for animal victim's owner):

Owner of Animal:

Last

First

Mid.

Date of Birth

Last Name

Street Address

City

Zip

Sex

Home Telephone

Work Telephone

First Name

Sex

Biting Animal

Color/Markings

Name

Sex

Date of Birth

Dog

Cat

Other

Street Address

City

Zip

Telephone

Neutered

Home:

Breed

Work:

Parent if victim is a juvenile:

Animal's Veterinarian

Prior Incidents

Last

First

Mid.

Rabies Vaccine

Date

Street Address

City

Zip

Telephone

Home:

Rabies Tag Number

License Number

Microchip Number

Citation issued?

Work:

If animal victim:

Location of Quarantine

Breed/Species

Color/Markings

Name

Vaccine Date (rabies)

Date of Quarantine

Quarantined by (name)

Release Date

Sex M F

Time of bite

Released from Quarantine by (name):

(if animal victim)

Treating Physician (or veterinarian)

Quarantined?

Name:

Owner release card (date received):

Yes No

Telephone:

Released from shelter quarantine (date):

Location on Body and Extent of Injury:

Lab #/Result:

Victim's statement of incident (animal owner if animal victim):

Animal owner's statement of incident:

Owner

Animal

Quarantine

Incident

State Department of Health required information (must be completed):

Species (fill in the correct biting species):

Bat	Dog	Hamster	Raccoon
Cattle	Ferret	Horse	Rat
Cat	Fox	Mouse	Squirrel
Chipmunk	Gerbil	Rabbit	Other

If Other, specify

Did the animal exhibit any of the following:

Convulsions Aggression Inability to eat/drink

Excessive salivation

Paralysis

Depression

Circumstances:

Animal confined (indoors, penned, tethered, or on leash) Animal not confined (stray, roaming, etc.)

Wild Animal	Provoked	Unprovoked
Unknown	Other
Action taken with animal:
No Action		Body destroyed
Escaped/not found		Head sent to ISDH Lab
Pet quarantined (see dates above)		Other
(dog, cat, ferret only)		Unknown
		Unknown

I, the undersigned, have received a copy of the quarantine guidelines, have read them, and understand them. I agree to comply with all provisions of the quarantine guidelines and understand that noncompliance may result in seizure of my pet if it is in home quarantine or loss of my pet if it is not properly claimed at the end of the quarantine period from the quarantining agency.

Witness___________________________________

Date __________________

Signature__________________________________________

DISTRIBUTION: White - Enforcing Agency, Canary - Local Health Department, Pink - Owner

Animal Bite Classification System – Proper Use

Bites are classified alphanumerically. The alpha designation indicates the victim, geographic location, and if the animal has bitten previously. The numeric designation indicates severity with (1) the least severe and (5) the most severe.

Section I – Victim	Section II – Confined/Stray	Section III – Repeat Biter	Section IV – Bite Severity
H = Human	C = Confined at the time of	R = Repeat biter, previous	1.	Minor Scratch
	the bite	information on file	2.	Minor, punctures 4 or
D = Other animal				less
(domestic)	S = Stray, roaming, off	O = No previous bites	3.	Moderate, punctures
	property, or not legally		4.	Severe, punctures (4 or
W = Other animal	restrained			more) deep may include
				crushing or tears from
				shaking
			5.	Death

Example: H/C/R/3 = A bite to a human; the animal was legally confined at the time of the bite; the animal has bitten previously, and this is a bite of moderate severity.

Initial Owner/Victim Contact – Action for Quarantine

Location:		Description:
Date:	Officer:		Results:

Failed Quarantine (indicate reason):

Victim contacted on the 10th day:

Date:

Agent contacting victim:

Individual spoke with:

Reserved space for office use:

QUARANTINE GUIDELINES AND INFORMATION

If your animal has been quarantined at a shelter or local veterinarian, the required date to pick up the pet is___________________________________. If you do not reclaim your pet

from (or make arrangements with) the quarantining agency by the end of the business day of the date entered above, and pay appropriate fees at the time of reclaim, the animal will become the property of the agency at that time. The disposition of the animal may be determined at that time by the quarantining agency.

INSTRUCTIONS FOR A HOME QUARANTINE

(Location of quarantine is at the discretion of the quarantining agency.)

1.Facility used for confinement shall ensure an escape-proof environment subject to unannounced periodic spot checks by the animal control officer or local health officer. The animal shall be confined inside a structure, not on a chain or in a fenced yard. Diagrams for the construction of cat and dog isolation cages are available if such is recommended by the animal control officer or local health officer.

2.The animal shall not leave the quarantine premises for any reason. The animal shall not have contact with humans or other animals for the 10-day period, with the exception of the primary caretaker.

3.At the first sign of illness in the animal, the owner shall notify the quarantining agency. Symptoms to watch for include fever, loss of appetite, excessive irritability, unusual vocalization, change in behavior, restlessness, jumping at noises, trouble walking, excessive salivation, tremors, convulsions, paralysis, stupors, or unprovoked aggression.

4.At the end of the 10-day quarantine period, the owner is responsible for contacting the quarantining agency to report the health status of the animal.

5.If these guidelines cannot be met or are violated at any time during the quarantine, the animal will be seized and the 10-day quarantine will be completed at the department of animal control shelter or a facility designated by the local health officer.

6.When a pet has been exposed to rabies and it is not vaccinated, euthanasia is recommended. Alternatively, the owner has the option of arranging for a six-month quarantine at the owner’s expense. This is due to the special public health risks associated with these animals (i.e., those potentially incubating rabies) and the need to prevent human and other animal exposures from occurring should rabies symptoms develop.

MEDICAL INFORMATION FOR VICTIMS AND PET OWNERS

Questions regarding medical treatment and advice should be directed to your family physician. Concerns regarding tetanus toxoid and/or rabies prophylaxis may be addressed by your physician or the local health officer. If your pet has been injured by another animal, contact your veterinarian for appropriate treatment.

Question	Answer
Form Name	State Form 14072
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	dog bite report form for indiana, in state dept health form 47970, indiana bites report fillable', cps report form indiana

State Form 14072 – Fill Out and Use This PDF

State Form 14072 PDF Details

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