Incident Report

Coordinator *

Date of Report: *

Dane's Name *

Names of persons involved (Please list all) *

Date of Incident: *

Name and Contact info. for witnesses to the event *

Was the dane a: *

MAGDRL Foster

MAGDRL Adopted Dane

Possible Owner Turn In

Other

Name & contact info for owner or foster of the Dane *

Dane Information

Dane's Age *

Sex *

Intact Male

Neutered Male

Intact Female

Spayed Female

If Dane is intact, please briefly explain why? *

Date Last seen by vet: *

Last date for bloodwork:

Describe the health of the Dane: *

Incident Information

Location of incident *

Incident took place: *

Indoors

Outdoors

If Indoor, specific room

Time of day incident occurred: *

How long since the dog was adopted? *

Did the incident involve: *

another dog

a cat

an animal

a person

Were there any warning signs? Growls, air snaps, barking, whining, others please explain. *

What happened in the weeks prior to the incident? Detail anything at all, including what was considered "normal" behavior. *

Did dog snap air/grab clothing, mouth hand or body part, mouth and hold, bite with no puncture wounds, bite with puncture wounds, bite with severe wounds (requiring stitches)? *

If a bite did occur, please explain injuries.

If it was a dog fight, did the dogs stop fighting when surrender was apparent?

Yes

No

If it was a dog fight, who broke it up?

If it was a dog fight and a person broke it up, how did they do so?

Please provide details about the incident, including a few hours leading up to it, how it started, and how it ended. *

If incident was with a human, what interaction between the dog and person took place before the incident?

Where were people located when the incident occured (all people, please)? *

Did the incident result in a trip to the hospital or doctors? *

Yes

No

If there was a hospital or doctor's visit what was the outcome (stitches, tetnus shot, ect.)?

Other Information

What is expected to happen to the dog (needs kenneling, put down, etc.)? *

What is the next course of action? *

Comments or suggestions?

Name of person completing this form? *