Form 14072 "Official Indiana Animal Bites Report" - Indiana

What Is Form 14072?

This is a legal form that was released by the Indiana State Department of Health - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2004;
  • The latest edition provided by the Indiana State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 14072 by clicking the link below or browse more documents and templates provided by the Indiana State Department of Health.

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Download Form 14072 "Official Indiana Animal Bites Report" - Indiana

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Official Indiana Animal Bites Report
Indiana State Department of Health
Sta te Form 14072 (R3/4-04)
Reporting Agency Case Number
Incident Location Address
Reported by (name)
Reporting Agency
/
/
/
Bite Classification
Reported by (phone)
(see reverse side of this page to classify)
County
/
/
Incident
On
Off
Property
Received by (name)
Exposure Date
Victim Type (circle 2)
Human
Animal
Juvenile
Adult
Release Date
Reported Date
Reported Time
VICTIM INFORMATION
OWNER INFORMATION
Person bitten
(if animal victim, use this space for animal victim's owner):
Owner of Animal:
Last
First
Mid.
Date of Birth
Last Name
Sex
Street Address
City
Zip
M
F
Home Telephone
Work Telephone
First Name
/
/
M
F
Sex
Color/Markings
Name
Sex
Biting Animal
Date of Birth
M
F
Dog
Cat
Other
Street Address
City
Zip
Telephone
Neutered
Home:
Breed
Y
N
Work:
Animal's Veterinarian
Prior Incidents
Parent if victim is a juvenile:
Last
First
Mid.
Rabies Vaccine
/
/
Date
Y
N
Street Address
City
Zip
Telephone
License Number
Microchip Number
Citation issued?
Home:
Rabies Tag Number
Y
N
Work:
If animal victim:
Location of Quarantine
Breed/Species
Color/Markings
Vaccine Date (rabies)
Name
Date of Quarantine
Quarantined by (name)
Release Date
Sex
M
F
Time of bite
Released from Quarantine by (name):
(if animal victim)
Treating Physician (or veterinarian)
Quarantined?
Name:
Owner release card (date received):
Yes
No
Telephone:
Released from shelter quarantine (date):
Location on Body and Extent of Injury:
Lab #/Result:
Victim's statement of incident (animal owner if animal victim):
Animal owner's statement of incident:
State Department of Health required information (must be completed):
Circumstances:
Species (fill in the correct biting species):
Animal confined (indoors, penned, tethered, or on leash)
Bat
Dog
Hamster
Raccoon
Animal not confined (stray, roaming, etc.)
Cattle
Ferret
Horse
Rat
Wild Animal
Unprovoked
Provoked
Cat
Fox
Mouse
Squirrel
Unknown
Other
Chipmunk
Gerbil
Rabbit
Other
Action taken with animal:
No Action
Body destroyed
If Other, specify
Escaped/not found
Head sent to ISDH Lab
Did the animal exhibit any of the following:
Pet quarantined (see dates above)
Other
Convulsions
Aggression
Inability to eat/drink
(dog, cat, ferret only)
Unknown
Excessive salivation
Paralysis
Depression
I, the undersigned, have received a copy of the quarantine guidelines, have read them, and understand them. I agree to comply with all provisions of the quarantine
guidelines and understand that noncompliance may result in seizure of my pet if it is in home quarantine or loss of my pet if it is not properly claimed at the end of the
quarantine period from the quarantining agency.
Witness___________________________________
Date __________________
Signature__________________________________________
DISTRIBUTION: White - Enforcing Agency, Canary - Local Health Department, Pink - Owner
Official Indiana Animal Bites Report
Indiana State Department of Health
Sta te Form 14072 (R3/4-04)
Reporting Agency Case Number
Incident Location Address
Reported by (name)
Reporting Agency
/
/
/
Bite Classification
Reported by (phone)
(see reverse side of this page to classify)
County
/
/
Incident
On
Off
Property
Received by (name)
Exposure Date
Victim Type (circle 2)
Human
Animal
Juvenile
Adult
Release Date
Reported Date
Reported Time
VICTIM INFORMATION
OWNER INFORMATION
Person bitten
(if animal victim, use this space for animal victim's owner):
Owner of Animal:
Last
First
Mid.
Date of Birth
Last Name
Sex
Street Address
City
Zip
M
F
Home Telephone
Work Telephone
First Name
/
/
M
F
Sex
Color/Markings
Name
Sex
Biting Animal
Date of Birth
M
F
Dog
Cat
Other
Street Address
City
Zip
Telephone
Neutered
Home:
Breed
Y
N
Work:
Animal's Veterinarian
Prior Incidents
Parent if victim is a juvenile:
Last
First
Mid.
Rabies Vaccine
/
/
Date
Y
N
Street Address
City
Zip
Telephone
License Number
Microchip Number
Citation issued?
Home:
Rabies Tag Number
Y
N
Work:
If animal victim:
Location of Quarantine
Breed/Species
Color/Markings
Vaccine Date (rabies)
Name
Date of Quarantine
Quarantined by (name)
Release Date
Sex
M
F
Time of bite
Released from Quarantine by (name):
(if animal victim)
Treating Physician (or veterinarian)
Quarantined?
Name:
Owner release card (date received):
Yes
No
Telephone:
Released from shelter quarantine (date):
Location on Body and Extent of Injury:
Lab #/Result:
Victim's statement of incident (animal owner if animal victim):
Animal owner's statement of incident:
State Department of Health required information (must be completed):
Circumstances:
Species (fill in the correct biting species):
Animal confined (indoors, penned, tethered, or on leash)
Bat
Dog
Hamster
Raccoon
Animal not confined (stray, roaming, etc.)
Cattle
Ferret
Horse
Rat
Wild Animal
Unprovoked
Provoked
Cat
Fox
Mouse
Squirrel
Unknown
Other
Chipmunk
Gerbil
Rabbit
Other
Action taken with animal:
No Action
Body destroyed
If Other, specify
Escaped/not found
Head sent to ISDH Lab
Did the animal exhibit any of the following:
Pet quarantined (see dates above)
Other
Convulsions
Aggression
Inability to eat/drink
(dog, cat, ferret only)
Unknown
Excessive salivation
Paralysis
Depression
I, the undersigned, have received a copy of the quarantine guidelines, have read them, and understand them. I agree to comply with all provisions of the quarantine
guidelines and understand that noncompliance may result in seizure of my pet if it is in home quarantine or loss of my pet if it is not properly claimed at the end of the
quarantine period from the quarantining agency.
Witness___________________________________
Date __________________
Signature__________________________________________
DISTRIBUTION: White - Enforcing Agency, Canary - Local Health Department, Pink - Owner
Animal Bite Classification System – Proper Use
Bites are classified alphanumerically. The alpha designation indicates the victim, geographic location, and if the animal
has bitten previously. The numeric designation indicates severity with (1) the least severe and (5) the most severe.
Section I – Victim
Section II – Confined/Stray
Section III – Repeat Biter
Section IV – Bite Severity
H = Human
C = Confined at the time of
R = Repeat biter, previous
1. Minor Scratch
the bite
information on file
2. Minor, punctures 4 or
less
D = Other animal
3. Moderate, punctures
(domestic)
S = Stray, roaming, off
O = No previous bites
property, or not legally
4. Severe, punctures (4 or
more) deep may include
restrained
W = Other animal
crushing or tears from
shaking
5. Death
Example: H/C/R/3 = A bite to a human; the animal was legally confined at the time of the bite; the animal has bitten
previously, and this is a bite of moderate severity.
Initial Owner/Victim Contact – Action for Quarantine
Location:
Description:
Date:
Officer:
Results:
Failed Quarantine (indicate reason):
th
Victim contacted on the 10
day:
Date:
Agent contacting victim:
Individual spoke with:
Reserved space for office use:
QUARANTINE GUIDELINES AND INFORMATION
If your animal has been quarantined at a shelter or local veterinarian, the required date to
pick up the pet is___________________________________. If you do not reclaim your pet
from (or make arrangements with) the quarantining agency by the end of the business day of the
date entered above, and pay appropriate fees at the time of reclaim, the animal will become the
property of the agency at that time. The disposition of the animal may be determined at that time
by the quarantining agency.
INSTRUCTIONS FOR A HOME QUARANTINE
(Location of quarantine is at the discretion of the quarantining agency.)
1. Facility used for confinement shall ensure an escape-proof environment subject to
unannounced periodic spot checks by the animal control officer or local health officer. The
animal shall be confined inside a structure, not on a chain or in a fenced yard. Diagrams for
the construction of cat and dog isolation cages are available if such is recommended by the
animal control officer or local health officer.
2. The animal shall not leave the quarantine premises for any reason. The animal shall not have
contact with humans or other animals for the 10-day period, with the exception of the
primary caretaker.
3. At the first sign of illness in the animal, the owner shall notify the quarantining agency.
Symptoms to watch for include fever, loss of appetite, excessive irritability, unusual
vocalization, change in behavior, restlessness, jumping at noises, trouble walking, excessive
salivation, tremors, convulsions, paralysis, stupors, or unprovoked aggression.
4. At the end of the 10-day quarantine period, the owner is responsible for contacting the
quarantining agency to report the health status of the animal.
5. If these guidelines cannot be met or are violated at any time during the quarantine, the animal
will be seized and the 10-day quarantine will be completed at the department of animal
control shelter or a facility designated by the local health officer.
6. When a pet has been exposed to rabies and it is not vaccinated, euthanasia is
recommended. Alternatively, the owner has the option of arranging for a six-month
quarantine at the owner’s expense. This is due to the special public health risks
associated with these animals (i.e., those potentially incubating rabies) and the need to
prevent human and other animal exposures from occurring should rabies symptoms
develop.
MEDICAL INFORMATION FOR VICTIMS AND PET OWNERS
Questions regarding medical treatment and advice should be directed to your family physician.
Concerns regarding tetanus toxoid and/or rabies prophylaxis may be addressed by your physician
or the local health officer. If your pet has been injured by another animal, contact your
veterinarian for appropriate treatment.
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