Bite/Scratch Report
Please complete the yellow shaded areas of this form and submit. If you have any questions, please contact Curricular Support at csteam@ucdavis.edu.
Victim
Name
txtVictimName
...
Email
txtVictimEmail
Employee/Student ID
txtVictimID
Date of Birth
Phone
txtVictimPhone
Cell
txtVictimCell
Address
txtVictimAddress1
City
txtVictimAddressCity
State
txtVictimAddressState
Postal Code
txtVictimAddressPostalCode
Student/Staff
Student
Staff
Selection
Injury
Date of Injury
Explain the circumstances under which the bite/scratch occurred. Include animal type, site injured, and the location/building where injury occurred.
Animal
Status
Feral
Pet
Research
Teaching
Wild
Unknown
Selection
Species
txtAnimalSpecies
Breed
txtAnimalBreed
Age
txtAnimalAge
Sex
Female
Female Spayed
Male
Male Castrated
Other
Selection
Other
txtAnimalSexOther
Color/Description
txtAnimalDescription
Rabies Vaccination
Yes
No
Selection
Vaccination Date
Serial #
txtAnimalRabiesVaccinationSerialNumber
Manufacturer
txtAnimalRabiesVaccinationManufacturer
License#/Jurisdiction
txtAnimalLicenseNumber
Patient Number
txtAnimalPatientNumber
Microchip #
txtAnimalMicrochipNumber
Did the animal appear ill or injured?
Yes
No
Selection
Please describe the illness or injury. 2000 characters maximum. Please include any witnesses and their contact information.
Animal Location and Owner/Shelter/Protocol
Current Location
txtAnimalLocation
Future Location
Foster
No change
Shelter
To Be Determined
Selection
Name of PI
txtPIName
...
Phone
txtPIPhone
Protocol # (Research/Teaching)
txtProtocolNumber
Shelter Agency
txtShelterAgencyName
Shelter Contact
txtShelterAgencyContact
Shelter Phone
txtShelterAgencyPhone
Date Discharged from UCD
Owner/Foster Name
txtOwnerFosterName
Owner/Foster Address
txtOwnerFosterAddress1
City
txtOwnerFosterAddressCity
State
txtOwnerFosterAddressState
Postal Code
txtOwnerFosterAddressPostalCode
Owner/Foster Phone
txtOwnerFosterPhone
Medical Care
First Aid Provided?
Yes
No
Selection
Please describe the first aid provided.
Medical Care Provider
txtMedicalCareProviderName
Medical Care Provider Address
txtMedicalCareProviderAddress1
City
txtMedicalCareProviderAddressCity
State
txtMedicalCareProviderAddressState
Postal Code
txtMedicalCareProviderAddressPostalCode
Phone
txtMedicalCareProviderPhone
Clinician, Instructor, Supervisor, or Other Contact
Please provide supervisor or other contact information for follow-up questions on injury or animal location.
Name
txtSupervisorContactName
Address
txtSupervisorContactAddress1
City
txtSupervisorContactAddressCity
State
txtSupervisorContactAddressState
Postal Code
txtSupervisorContactAddressPostalCode
Phone
txtSupervisorContactPhone
txtSupervisorContactTitle
Title
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