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

Introduction

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Location incident

Do you speak and understand English?*
Are you affected by alcohol or any drugs?*
Are you...?

Personal information

Gender*

Contact details

Current residential address

Description of your dog/s

Gender of the dog*
is/are the dog registered*
Is/are the dogs/s microchipped?*
Are you aware of an incident regarding an alleged dog attack?*
Was anyone else looking after your dog/s at the time of the incident?*
If not, where does the dog/s ordinarily live?
Were there any injuries?*

Details of the incident - Part A

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

Witness details


Details of the incident - Part B

Where were you at the time of the incident?

Details of the incident - Part C

Has the dog/s ever shown any aggressive behaviour in the past?*
Has the dog/s ever been declared dangerous, within the Town or within another jurisdiction?*
Have you ever received infringements or been convicted for breaches of the Dog Act 1976 (WA)?

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Declaration

Have you been made any promises or inducement to provide this statement?*
Is this statement made of your own free will?*
Have you been threatened by any person to make this statement?*
Do you agree this is a true statement?*
Do you understand that by making this statement that if it is tendered in evidence I will be guilty of a crime if I have willfully included in this statement anything, which I know to be false, or that I do not believe to be true?*

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