Special Risk Reporting

Incident Report - Incomplete submissions will not be included

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* 1. Which County did the incident occur?

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* 2. Date of Incident

Date / Time

Date

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* 3. How would this incident be most appropriately categorized?

Animal attack

Non-Physical Verbal Assault and/or Threats

Physical Assault, unlawful touch or strike

Assault with a potentially deadly weapon

Other (please specify)

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* 4. Did the victim require treatment? (Check those that are applicable)

No treatment required

Basic first aid in the field

Treatment administered by paramedics in the field

Treatment provided at a hospital or urgent care facility

Hospitalization required for advanced treatment

Victim died

Physical therapy

Mental counseling

Other (please specify)

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* 5. Was Law Enforcement involved and if so, which agency (no abbreviations please) and what was their case number?

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* 6. Was an arrest made?

Yes

Other (please specify)

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* 7. Is the victim an animal control officer?

Yes

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* 8. What is the full name of the agency where the victim is employed?

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* 9. What is the victim's agency case number?

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* 10. What is the best contact information for the victim?

Name

Email Address

Phone Number

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* 11. What is the best contact information for the victim's supervisor?

Name

Email Address

Phone Number

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* 12. What is the best contact information for you, as the incident submitter?

Name

Email Address

Phone Number

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* 1. Which County did the incident occur?

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* 2. Date of Incident

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* 3. How would this incident be most appropriately categorized?

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* 4. Did the victim require treatment? (Check those that are applicable)

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* 5. Was Law Enforcement involved and if so, which agency (no abbreviations please) and what was their case number?

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* 6. Was an arrest made?

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* 7. Is the victim an animal control officer?

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* 8. What is the full name of the agency where the victim is employed?

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* 9. What is the victim's agency case number?

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* 10. What is the best contact information for the victim?

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* 11. What is the best contact information for the victim's supervisor?

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* 12. What is the best contact information for you, as the incident submitter?

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* 13. Please provide a brief summary of the incident: