This form may be completed by the bitten or exposed person, their healthcare provider, or anyone with knowledge of the incident.
Healthcare providers: Healthcare providers can satisfy state animal bite reporting requirements by ensuring that this form is completed during a patient visit.
Animals bitten by animals: Reporting animals bitten by other animals is not required.
Privacy: This information will be kept confidential to the maximum extent possible by all applicable state and federal privacy laws.
Shared with: It will be shared with the local health department serving the bitten or exposed person's home address.
| Question | Answer |
|---|---|
| Form Name | State Form 14072 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 136 |
| Avg. time to fill out | 23 min |
| Edition | R6 / 7-26 |
| Issuing agency | Indiana Department of Health |
| Other names | State Form 14072, Form 14072, 14072, Indiana animal bite report |
| Official source | State Form 14072 (Rev R6 / 7-26), Indiana Department of Health |
State Form 14072 isn’t the one you’re looking for?