Form Center

2. 
3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894
   Animal Bite Report
5. Individual Completing Form
7. Name*
8. Agency
10. Phone Number*
11. Fax Number
13. Email Address
15. Date and Time of Bite
    Date and Time of Bite

    Date and Time of Bite
19. Person Bitten
21. Name*
22. Email Address
24. Address*
26. City*
27. State*
28. Zip Code*
30. Phone Number*
32. Age*
33. Give Parents Name
35. Part of Body Bitten
37. Address Where Bite Occured
39. City
40. State
41. Zip Code
45. Animal Information
47. Kind of Animal*
48. Animal Type*

    1. Domestic
    2. Stray
    3. Wild
    4. Unknown
50. Animal Name / Color / Breed / Sex:
52. Owners Name
53. Email Address
55. Address
57. City
58. State
59. Zip Code
61. Phone Number
63. Was The Animal Killed?*

    1. Yes
    2. No
    3. Unknown
64. Did The Animal Die?*

    1. Yes
    2. No
    3. Unknown
66. Address Of Animal If Different From Owner's
68. City
69. State
70. Zip Code
72. Circumstances Of Bite*
Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field