Dog Incident Report

Dog Incident Report and Investigation Agreement

Report Number:    Date of Report:    Time:

Parties and Recitals

Reporting Party Name:    Contact Phone:

Responsible/Owner Name:    Owner Phone:

WHEREAS, the Reporting Party has alleged that a dog-related incident occurred involving the dog(s) identified in this report; and

WHEREAS, the Responsible/Owner acknowledges receipt of this report and agrees to cooperate in the investigation and any required remedial actions; and

WHEREAS, the parties desire to document the incident facts, agree the scope of the investigation and any associated costs, and set forth confidentiality and dispute resolution provisions.

Scope of Investigation

The Responsible/Owner retains the Reporting Party or designated investigator to gather facts, witness statements, and evidence related to the incident and to prepare a written investigative report. Activities may include site inspection, witness interviews, veterinary record review, and photographic documentation.

Incident Details

Incident Date:    Incident Time:

License Number:    Vaccination Status: Up to date Not up to date

Victim and Witness Information

Veterinary treatment required: Yes No    Estimated veterinary expenses: $

Reported to law enforcement or animal control: Yes No    Agency/Case Number:

Actions Taken

Animal confined following incident: Yes No    Confinement location:

Payment Terms for Investigation and Costs

Investigation Fee Amount: $

Late Fee for overdue payments:    Payment Responsibility:

Term and Termination

Agreement Start Date:    Agreement End Date:

Termination requires written notice of days delivered to the other party. Termination will not relieve a party of obligations accrued prior to the effective termination date.

Confidentiality

All non-public information, witness identities (unless required by law), investigative materials, and medical records obtained in connection with this incident shall be treated as confidential and may only be disclosed as required by law or as necessary for enforcement proceedings. The parties agree to use such information solely for purposes of investigation, remediation, and related legal processes.

I acknowledge and agree to the confidentiality provisions above.

Governing Law and Entire Agreement

This Agreement will be governed by and construed in accordance with the laws of the state of , without regard to its conflict of law principles.

This document constitutes the entire agreement between the Reporting Party and the Responsible/Owner with respect to the subject matter hereof and supersedes all prior and contemporaneous understandings, whether written or oral. Any amendment must be in writing and signed by both parties.

Certification

By signing below, the undersigned certifies that the information in this report is true and correct to the best of their knowledge, that they have disclosed material facts they are aware of, and that they understand the potential legal consequences of materially false statements.

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