First name of victim Age of victim * Victim's gender * Male Female Date of incident * City & state where incident happened * Breed involved in attack (or answer do not know) * Was the dog known to be aggressive prior to the attack on the victim? Yes No Do not know How familiar was the victim with the dog? * Very familiar Somewhat familiar Did not know Was the dog chained or did it break away from a chain at the time of attack? * The dog was not chained The dog was chained The dog broke away from a chain Did the victim and dog live in the same household? * Yes, victim live with dog No, victim did not live with dog Victim's behavior immediately before attack Direct social interacting with dog No interaction with dog Location on body where victim was bitten Mostly on head and face Mostly on torso Legs or feet Multiple bites on entire body How many stitches did the victim require? Less than 20 stitches More than 20 stitches Was victim hospitalized? * Yes No Additional comments Consent to having this info forwarded to an attorney? * Yes No e-mail