Online Form - Rangers - Dog Attack Statement - Dog Owner or Person in Control

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Introduction
Incident details
What we need to know
Description of your dog/s
Details of the incident - Part A
Witness details
Details of the incident - Part B
Details of the incident - Part C
Declaration
Submit Response

Introduction

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Date of incident*

Approximate time of the incident*

Location incident*

Do you speak and understand English?*

YesNo

Are you affected by alcohol or any drugs?*

YesNo

Are you...?

Dog OwnerPerson In Control

Personal information

First name*

Last name*

Date of birth*

Gender*

MaleFemale

Contact details

Current residential address

Street Address:*

City:*

State:*

Post Code:*

Country:*

Contact number*

Email*

Description of your dog/s

Details of the incident - Part A

If your dog/s escaped your property, how did the dog/s get out?*

Were there any witnesses to the incident? If Yes, provide names and contact details on the next page*

YesNo

Witness details

Full name -1

Contact number - 1

Email -1

Full name - 2

Contact number - 2

Email - 2

Full name - 3

Contact number - 3

Email - 3

Details of the incident - Part B

Where were you at the time of the incident?*

What happened immediately prior to the attack?*

What happened during the attack?

What happened immediately after the attack?*

Details of the incident - Part C

Has the dog/s ever shown any aggressive behaviour in the past?*

YesNo

Has the dog/s ever been declared dangerous, within the Town or within another jurisdiction?*

YesNo

Have you ever received infringements or been convicted for breaches of the Dog Act 1976 (WA)?

YesNo

If yes, where was it declared as a dangerous dog?

Date of the infringement (if known)

Is there anything else you wish to disclose in relation to this matter?

If you saw the attack, please sketch the locality of the attack/include street name and house number, verge/footpath. Please attach below

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Declaration

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