2. First Name of Reporting Party:*
3. Last Name of Reporting Party:*
5. Address of Reporting Party:*
7. City*
8. State*
9. Zip Code*
11. Phone Number of Reporting Party:*
12. Email Address of Reporting Party:*
16. Date and Time of Interaction:*
    Date and Time of Interaction:

    Date and Time of Interaction:
17. Duration of Interaction:*
19. Location of Interaction:*
20. Location Type:*
    -- Select One --CommercialParkResidentialVacant
22. Activity of Reporting Party prior to interaction:*

    (e.g. walking, running, cycling, etc.)

23. Type of Interaction:*
    -- Select One --AttackEncounterIncidentObservationSighting
25. Was the coyote being intentionally fed?*

    1. Yes
    2. No
26. Was there pet food present?*

    1. Yes
    2. No
27. Was unsecured garbage present?*

    1. Yes
    2. No
29. Were other food attractants present?*

    (e.g. bird seed, compost, fruit, etc.)

    1. Yes
    2. No
30. Please describe attractant:*
32. Please describe the interaction with the coyote:*
36. Was a pet involved?*

    1. Yes

    1. No
38. Type of pet:*

    1. Cat
    2. Dog
    3. Other
39. Describe breed and weight of pet:*
41. Was pet on a leash/lead?*
    -- Select One --Yes, leash/lead was LONGER than 6 ftYes, leash/lead was SHORTER than 6ftNo
43. Condition of pet after interaction:*
    -- Select One --Thankfully, no harm was doneInjuredKilled
44. Please describe injuries pet sustained:*
48. Please describe actions taken by reporting party:*

    (e.g. ran away, hazed coyote, screamed, none, etc.)

49. How did coyote respond:*

    (e.g. ran away, approached, etc.)

51. Please describe outcome of interaction:*
53. Was any person(s) injured during interaction?*

    1. Yes
    2. No
54. Who was injured?*
    -- Select One --MyselfSomeone Else
56. Name of Injured Person(s):*
57. Approximate Age(s) of Injured Person(s):
59. Please describe injuries sustained:*
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

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