ANIMAL BITE or SCRATCH REPORTING FORM

(Must be completed for ALL animals bites or scratches)

I. Person Bitten/Scratched (completed by the person bitten/scratched by animal): / PRINT
Last Name: / First Name: / DOB:
SID#:
UC Dept and Supervisor’s Name and Phone Number:
Local Address:
City: / State: / Zip:
Phone: / Fax: / Date bitten:
UC Status:(Circle once) / UC Employee / UC Student / Vet Student / No Affiliation
Did the animal appear ill? Describe: / Describe the Bite/Scratch, include location on body:
Date reported to Supervisor:
In the space below, explain the circumstances under which the bite/scratch occurred (include physical location of where the incident took place):
City: / State: / Zip:
II. The Animal (completed by the person bitten/scratched):
Species: / Breed/Type: / Name or ID# of Animal:
Sex: / Color: / Age:
Vaccinated for Rabies? /
  • Yes
/
  • No
/ Date vaccinated:
License #: / License jurisdiction:
  • Pet?
/
  • Research?
/
  • Wild?
/
  • Feral?

Health Status: / Current Location:
Owner’s Name: / Day Phone: ( )
Street Address: / City and Zip:
Mailing Address: / City and Zip:
III. Reported By (completed by medical personnel helping patient):
Last name:
(MD/FNP) / First name:
Last name:
(RN/Medical) / First name:
Address: Student Health and Counseling Services, University of California, Davis / First date of care:
City: Davis / State: California / Zip: 95616
Phone: (530) 752-2300 / Fax: (530) 752-5587
Date: / Signature:
Date: / Signature:

Instructions: Bitten UCD students should report to Student Health and Counseling Services (530-752-2300). Bitten individuals who are UCD employees must report to Occupational Health Services (530-757-3200) for treatment and evaluation. If you are not certain the bite has been reported, report it again.

Completed form must befaxed within 24 hours of the bite/scratch to:

  1. Yolo County Animal Services Section (530-668-5288)
  2. Campus Veterinarian’s Office (530-754-4350) Attn: Nicole Corley

Report faxed on (date)______by______(fax confirmationattached)

Original to QI Manager Medical Director Reviewed

04/04, 03/06, 01/07, 06/08, 11/08, 11/10, 08/14 MRC: 03/06