Dog attack or menacing dog report

Companion Animals Act 1998

Privacy Statement: The information on this form is being collected by Council for purposes associated with responding to your report. It will be used by Council officers for purposes relating to acting upon the report, and may be disclosed to persons and/or organisations outside of Council. Supply of this information is voluntary, but without it Council cannot act on your report. View our privacy statement for more information.

Part 1: Details of person attacked or menaced

Victim's full name * No initials

Age in years *

Address *

Contact name * (If not the victim)

Relationship to victim

Daytime phone *

Mobile

Email address

I agree to receive correspondence about this report by email

Part 2: Details of animal attacked or menaced

Details of injured animal *

Type of animal

Microchip number (If known)

Animal owner's contact name (If known)

Address

Daytime phone

Mobile

Details of veterinary surgeon treating injured animal

Part 3: Description of attacking or menacing dog

Breed or type *

Age * (Approximate)

Sex

Colour *

Other identifying features *

Part 4: Details of dog attack or menacing behaviour

Where did it happen? * Address or location

When? *

Day Month Year Hour Minute

What were you doing at the time? *

Who was with you? *

Were you injured?

What are your injuries? *

Did you need medical treatment?

Were you given a medical certificate?

Doctor's name and address

Were any photos taken?

Please upload any photos taken You can upload one file at a time. Maximum file size: 20MB Format: JPEG, PDF

Witness 1 name

Witness 1 address

Witness 1 phone number

Witness 2 name

Witness 2 address

Witness 2 phone number