Online Form - Rangers - Dog Attack Statement - Victim/Injured Party

Introduction

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Do you speak and understand English?*

YesNo

Are you affected by alcohol or any drugs?*

YesNo

Would you be willing to attend court to give evidence?*

YesNo

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*

I became aware of an incident regarding an alleged dog attack by:

Date you became aware of the attack*

How did you become aware of attack?*

Details of the incident - Part A

Date of the incident*

Location of the incident*

Approximate time of the incident*

Details of the incident - Part B

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 C

The dog/s involved in the attack is/are described as follows:

Gender of the dog

MaleFemale

Breed of the dog (if known)

Colour of the dog (if known)

I can identify the attacking dog/s?*

YesNo

The attacking dog/s owner at the time of the attack was:*

I can identify the attacking dog/s owner?*

YesNo

If Yes, provide description of the owner

Details of the incident - Part D

Did you sustain injuries as a result of the attack?*

YesNo

If Yes, provide description of injuries sustained

If you received the following medical treatment, please provide medical reports and invoices

Upload medical reports and invoices here

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

I continue to be impacted by the attack in the following ways:

Did your pet sustain injuries as a result of the attack?*

YesNo

If Yes, provide description of injuries of your pet sustained

My pet underwent treatment as a result of the attack: *Please provide veterinarian reports and invoices

Upload veterinarian reports and invoices

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Prior to the attack:*

During the attack:*

After the attack:*

Further details I wish to disclose regarding the attack are:

Details of the incident - Part E

Sketch of the locality of attack/include street name and house number, verge/footpath

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

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Online Form - Rangers - Dog Attack Statement - Victim/Injured Party

Navigation

Introduction

Save Your Progress

I became aware of an incident regarding an alleged dog attack by:

Details of the incident - Part A

Details of the incident - Part B

Witness details

Details of the incident - Part C

Details of the incident - Part D

Details of the incident - Part E

Declaration

Validate and Submit Form