Dog Park Incident Report Form

For unresolved incidents occurring at Chandon Dog Park in Herndon, VA

Print this form, complete it, and mail to:

Herndon Dogs, Inc. Post Office Box 250 Herndon, Virginia 20170

Date of Incident: ________________________

Offending Parties (check all that apply)

      ___ Dog(s)        ___ Dog Guardian(s)    ___ Other (please describe) _________________________________

Approximate time of Incident: ________________________

Type of Incident

    ___ Dog Bite       ___ Dog Fight     ___ Aggressive Dog

    ___ Other (please describe) __________________________________

Parties Involved in This Incident (if more than 2, please describe additional parties on back of this form)

    Party 1 Involved in Incident __________________________________

    Party 2 Involved in Incident __________________________________

    Dog’s Name __________________________________

    Description of Dog __________________________________

    License and/or Rabies Tag __________________________________

    Human’s Name ________________________    Phone _________________

    Address _______________________________________

    __________________________________

    Email __________________________________

    Vehicle (Description, License) __________________________________

Witnesses to This Incident (if more than 3, please describe additional parties on back of this form)

Witness 1 __________________________________    Phone __________

     Address __________________________________   Email _________________

Witness 2__________________________________    Phone __________

     Address __________________________________   Email _________________

Witness 3__________________________________    Phone __________

     Address __________________________________   Email _________________

Description of This Incident

Nature of Injuries, if any __________________________________

____________________________________________________

Other information that may help resolve the incident satisfactorily to all parties

____________________________________________________

____________________________________________________

____________________________________________________

This Report Submitted By _________________________________________

Address____________________________________________________

Phone________________     Email ________________

Incident Report Procedures

See Dog Park Etiquette

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