| *Email |
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| Organization, if any |
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| *First name |
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| *Last name |
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| *Address line 1 |
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| Address line 2 |
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| *City |
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| *State or Province |
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| *Zip or postal code |
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| *Country |
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| Home phone |
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| Work phone |
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| Cell phone |
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| *Date of trapping incident |
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| *City or town where incident took place |
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| *County where incident took place |
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| *State or province where incident took place |
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| *Area where trap was set |
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| *Habitat description (urban, suburban, forest, campground, stream, etc.) |
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| *Type of trap |
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| |
Other type of trap |
| *Type of animal trapped |
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| Was the animal a pet? |
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| Was the animal a hunting dog? |
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| *Estimate time (hours) animal spent in trap |
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| *Type/result of injury (check all that apply) |
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| Name of attending veterinarian (if applicable) |
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| To what agency, if any, was the incident reported? |
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| *Was the trapper charged with a violation of trapping regulations or other laws? |
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| *If the trapped animal was a pet, did the trapper pay for treatment of the pet's injuries? |
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| If not, did the pet's owner bring civil action against the trapper or the state to recover costs? |
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| *Reason for your involvement |
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| Please provide photographs or newspaper articles pertaining to this incident that might be helpful to The HSUS. |
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| Please provide any additional details pertaining to this incident that might be helpful to The HSUS. |
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| *Would you or anyone else associated with the incident be willing to testify on behalf of or otherwise cooperate with The HSUS in programs to end the cruelty of trapping? |
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(If yes, please list names, addresses and telephone numbers below.) |
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| *I hereby give The Humane Society of the United States (HSUS) permission to use any of the information provided in, or in connection with, this form, including my identity and any pohotos or other materials provided with this form, in any way it sees fit, including use in HSUS publications and in testimony before legislative and judicial bodies. I verify that the information on this form is complete and accurate to the best of my knowledge. |
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| * = Required |
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