Shaker Field Dog Park Incident Report Form
This form should be completed for all Safety Issues and submitted to the Mascoma Valley Dog Park Supporters Board. Please refer to our Safety Protocol for further details (https://docs.google.com/document/d/15xvSIBR1TWxl2saAs_6SOPb3oyz8yha_-wcdyLhCNew/edit?usp=sharing)

Please complete as much as possible.

By submitting this form you agree that the above stated facts are true to the best of your knowledge.

Note: All incidents will be handled in as timely a manner as possible. Guidelines and rules of use for this facility can be found on our website at www.mascomavalleydogpark.com.

Email address *
Date and Time of Incident *
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Time
:
Location *
Your role in the incident *
Your Name (First and Last) *
This information will be kept confidential
Your answer
Provide your contact information, including address, phone number, and email
Your answer
Provide your dog(s) information, including name, breed, age, weight, and color
Your answer
Provide the names of all other individuals/dogs involved in the incident. Include contact information for owners, if you have it. In lieu of contact info, please be as descriptive as possible so that we can try to identify all involved parties.
Your answer
Describe the incident
Your answer
Describe injuries to humans (if none, skip)
Your answer
Describe injuries to dog(s) (if none, skip)
Your answer
Actions Taken (select all that apply)
Witnesses - please include the names of people who witnessed the incident, including as much identifying detail as possible (person's name, dog's name, vehicle description, and contact information, if you have it)
Your answer
Use this space to provide any additional information that may assist in an investigation.
Your answer
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