Dog Attack Report

I declare that all the information supplied in connection with this investigation is true and correct. The information provided sets out evidence I would be prepared (if necessary) to give in court as a witness. The supporting documents are true to the best of my knowledge and belief. I acknowledge that I will be liable to prosecution if I wilfully state anything that I know to be false, misleading or do not believe to be true. *

It is my understanding that an investigation will be conducted, in relation to this incident, under the provisions of the Companion Animals Act 1998. *

I understand that QPRC - Animal Management Services are not authorised to seek civil liability claims and I am to seek compensation through the small claims court for damages arising from this incident. *

Contact details

Full name *

Date of Birth

Postal address (all correspondence will be posted to this address)

Street addressStreet address line 2

City

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Phone number *

Email Address *

Details of attack

Did the dog/s rush at you? *

YesNo

Did the dog/s rush at your pet? *

YesNo

Did the dog/s harass you? *

YesNo

Did the dog/s harass your pet? *

YesNo

Did the dog/s chase you? *

YesNo

Did the dog/s chase your pet? *

YesNo

Did the dog/s attack you? *

YesNo

Did the dog/s attack your pet? *

YesNo

Did the dog/s attack result in any injuries to you? *

YesNo

Did the dog/s attack result in any injuries to your pet? *

YesNo

Did the dog/s bite you? *

YesNo

Did the dog/s bite your pet? *

YesNo

Were the dog/s with a person/s at the time of the incident? *

YesNo

Were the dogs under control or led by a person/s at the time of the incident? *

YesNo

Number of attacking dog/s? *123455+

Number of witnesses to the incident?123455+

Number of human victims?123455+

Number of animal victims?123455+

Location of the attack? (Include the name of a park or public place, or if upon private property the address if known) *

Date of the attack? *

Time of the attack? *

Description of the dog/s

Description of the offending dog/s (examples - disguising coat marks, items being worn, collar type, jackets).

Name of dog 1 (if known)

Name of dog 2 (if known)

Name of dog 3 (if known)

Sex of dog 1 (if known)

Sex of dog 2 (if known)

Sex of dog 3 (if known)

Breed of dog 1

Breed of dog 2

Breed of dog 3

Colour of dog 1

Colour of dog 2

Colour of dog 3

Distinguishing markings of dog 1

Distinguishing markings of dog 2

Distinguishing markings of dog 3

Approximate age of dog 1

Approximate age of dog 2

Approximate age of dog 3

Further details

Photographic Evidence - these photos will be attached to your statement of events for submission as evidence.

Did you take these photos?

YesNo

If no, who did?

Attach image 1

Browse

Attach image 2

Browse

Attach image 3

Browse

Attach image 4

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Where did the dog/s come from or reside? (If property address is not known provide a Park/Street name, attach a drawing or map

Attach a drawing or map

Browse

Name and contact details of any witnesses? (if applicable)

Name of witness 1

Name of witness 2

Address of witness 1

Address of witness 2

Phone number witness 1

Phone number witness 2

Email address witness 1

Email address witness 2

Is witness 1 prepared to supply a Statement?

YesNo

Is witness 2 prepared to supply a Statement?

YesNo

Is witness 1 prepared to attend court (if required)?

YesNo

Is witness 2 prepared to attend court (if required)?

YesNo

Details of report to third parties

Doctor's Report/Hospital Report

Doctor's name

Doctor/hospital phone number

Upload a copy of the Doctor's/hospital report

Browse

Vet's Report/Clinical notes

Vet's name

Clinic name

Clinic phone number

Upload copy of veterinary report

Browse

Upload copy of veterinary bill

Browse

NSW Police assistance

Police station

Contact number

Date reported

Time reported

Attending officer

Event number

Other details

Did you witness the dog/s being collected by anyone?

YesNo

Were the dog/s taken away in a vehicle?

YesNo

Did you get the registration number of the vehicle?

YesNo

Registration number of vehicle is

Did you restrain or impound the dog/s at the scene?

YesNo

Did any witness restrain or seize the dog/s?

YesNo

Did QPRC Animal Management Officers collect the dog/s?

YesNo

Did the offending dog owner/s collect the dog/s from the scene?

YesNo

Did the dog/s escape/run to an unknown location or were they unable to be restrained.

YesNo

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