Incident Report Form

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This field is for validation purposes and should be left unchanged.

Richmond SPCA employee completing this incident report:(Required)

First: Last:

Email address of the employee completing this incident report:(Required)

Name of notified Richmond SPCA supervisor:(Required)

Is this incident related to the Protection of Minors Policy?(Required)

Yes
No

Minor's Information

Minor involved in incident:(Required)

This individual must be 17 years of age or younger.

First: Last:

Minor's date of birth:(Required)

Minor's race(Required)

Minor's home address:(Required)

Street Address City State ZIP Code

Parent/Guardian's Information

Parent/Guardian's name:(Required)

First: Last:

Is the home address for the parent/guardian the same as the minor's?

Yes
No

Parent/Guardian's home address:(Required)

Street Address City State ZIP Code

Parent/Guardian's phone number:(Required)

Incident Details

Where did this incident occur?(Required)

Address where incident occurred:

Street Address City State ZIP Code

Who is the alleged abuser?(Required)

Alleged abuser's name:(Required)

First Last

Describe the incident that you are reporting:(Required)

Please provide as many details as possible.

Have you reported this incident to Child Protective Services?(Required)

Yes
No

How did you report this incident?(Required)

For example, did you call the Virginia Child Protective Services Hotline or did you report the incident to the local department of social services where the abuse occurred?

Have you reported this incident verbally to People Operations or a Richmond SPCA Officer?(Required)

Yes
No

Injured Person Information

Person involved in incident:(Required)

First: Last:

Date of birth:(Required)

Is this person a minor?(Required)

No, they are 18 or older.
Yes, they are under 18.

Pronouns:

Relationship to Richmond SPCA:(Required)

Staff
Foster Care Volunteer
Volunteer
Visitor

Department:

Home address:(Required)

Street Address: City: State: ZIP:

Phone number:(Required)

Email:(Required)

Parent/guardian's name:(Required)

First: Last:

Parent/guardian's relationship to person involved in incident:(Required)

Parent/guardian's phone number:

Please provide if different from phone number listed above.

Incident Details

Date of incident:(Required)

Time of incident:(Required)

:

Did this incident occur at the Richmond SPCA?(Required)

Yes
No

Name of location where incident occured (if applicable):

Address where incident occured:(Required)

Street Address: City: State: ZIP:

Was there a witness present for this incident?(Required)

Yes
No

Witness name:(Required)

First: Last:

Is the witness a Richmond SPCA staff member?(Required)

Yes
No

Witness' phone number:(Required)

Was an animal involved in this incident?(Required)

No
Yes, a Richmond SPCA shelter pet
Yes, an owned/public pet
Yes, a pet belonging to another agency
Yes, a community cat undergoing Trap-Neuter-Vaccinate-Return

Nature of injury:(Required)

Select all that apply.

Bite
Scratch
Other

Please describe the injury:(Required)

Location on the body of the injury:(Required)

Description of incident:(Required)

Was skin broken?(Required)

No
Yes

Medical attention sought?(Required)

No medical attention sought (yet)
Treated at the Richmond SPCA
Seeking/sought medical care

Location where medical attention was/will be sought:(Required)

Shelter Pet Information

Name of shelter pet:(Required)

Species:(Required)

Dog
Cat
Rabbit
Guinea Pig

Pet's coat color/markings:(Required)

Breed/mix:(Required)

Age:(Required)

Was this pet available for adoption at the time of the incident?(Required)

Yes
No

Has this pet been vaccinated for rabies?(Required)

Yes
No
I don’t know

Was this pet showing signs of illness at the time of the incident? If you are unsure, please see IVS.(Required)

Yes
No

Was the paw that scratched the victim wet at the time of the incident? This would be if the cat or dog in question was licking their paw before the incident.(Required)

Yes
No
I don’t know

Rabies expiration date:(Required)

Rabies tag number:(Required)

Date bite disclosure updated with this incident:(Required)

Location where animal is quarantined for 10 days:(Required)

Owned/Public Pet Information

Name of owned/public pet:(Required)

Species:(Required)

Dog
Cat
Rabbit
Guinea Pig

Pet's coat color/markings:(Required)

Breed/mix:(Required)

Age:(Required)

Was this pet showing signs of illness at the time of the incident?(Required)

Yes
No
I don’t know

Has this pet been vaccinated for rabies?(Required)

Yes
No
I don’t know

Rabies expiration date:(Required)

Rabies tag number:(Required)

Pet's owner:

First: Last:

Owner's phone number:(Required)

Owner's address:(Required)

This location will be where animal will be quarantined for 10 days.

Street Address: City: State: ZIP:

Pet Belonging to Other Agency Information

Name of pet belonging to another agency:(Required)

Species:(Required)

Dog
Cat
Rabbit
Guinea Pig

Pet's coat color/markings:(Required)

Breed/mix:(Required)

Age:(Required)

Has this pet been vaccinated for rabies?(Required)

Yes
No
I don’t know

Rabies tag number:(Required)

Rabies expiration date:(Required)

Agency/Organization:(Required)

Address of agency:(Required)

This location will be where animal will be quarantined for 10 days.

Street Address: City: State: ZIP:

Agency contact person:

First: Last:

Agency contact person's phone number:(Required)

Community Cat Information

Name of community cat:(Required)

Cat's coat color/markings:(Required)

Breed/mix:(Required)

Age:(Required)

Has this cat been vaccinated for rabies?(Required)

Yes
No
I don’t know

Rabies tag number:(Required)

Rabies expiration date:(Required)

Trap-Neuter-Vaccinate-Return practitioner:

First: Last:

TNVR practitioner's phone number:(Required)

TNVR practitioner's address:(Required)

This location will be where animal will be quarantined for 10 days.

Street Address: City: State: ZIP:

CAPTCHA

Minor's Information

Parent/Guardian's Information

Incident Details

Injured Person Information

Incident Details

Shelter Pet Information

Owned/Public Pet Information

Pet Belonging to Other Agency Information

Community Cat Information

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