Dog

Attack
Complaint
Complainant / Witness

Interview

with

The personal information collected on this form is for the purpose of recording the incident and to
determine the appropriate action to take and will not be disclosed to any other party unless
required by law.

Name of person making complaint (complainant)

Address of complainant

Phone
...
Date complaint lodged with Council ././. Time
..
Date of attack
.
Time . am/pm
Place of attack

.
Name of person(s) attacked

..

.
Address of person(s) attacked

.
Description of how the attack took place

.
Did the attack cause you fear? Yes / No

Dog Attack Witness Interview Form WOR-FRM-012

Dog
Attack
Complaint
Complainant / Witness

Interview

with

Describe on a scale of 1 to 5 your level of fear with 1 being the least and 5 being
the most fearful
Describe injuries to person(s) or other animals
..

.
Was medical attention required? Yes / No
If yes please provide details

.
Can Burke Shire Council contact the medical practitioner to provide details of the
injury and medical treatment provided only in relation to this matter? Yes / No

Dog Attack Witness Interview Form WOR-FRM-012

Dog
Attack
Complaint
Complainant / Witness

Interview

with

Description of dog
Breed .

Size Small / Medium /

Large
Colour (any distinctive markings)

Sex (if known)

Male / Female

Owner of dog (if known)

..
Dogs usual place of residence (if known)

.
List any witnesses to the attack and contact details if known

.
Was the owner present at the time of the attack? Yes / No
If yes, what action did the owner take at the time of the attack? .

.
If necessary does the complainant give authority for Burke Shire Councils
Authorised Officer to photograph the injury? Yes / No
(Note these photographs will be used as part of the official record of interview and
investigation records.)

Complainants signature ..
Date ././..
Burke Shire Council officer(s)

Dog Attack Witness Interview Form WOR-FRM-012

Dog
Attack
Complaint
Complainant / Witness

Interview

with

Name .. Signature

Position . Date ././

Name .. Signature

Position . Date ././

Dog Attack Witness Interview Form WOR-FRM-012