U.S. Trapping Incident Report Form

We know that it may be difficult for you, but if you are able to take photos of the incident and/or of the victim after treatment if applicable, that will help provide "proof" for media, legislators, prosecutors, etc. You'll find an address to send photos and newspaper articles at the bottom of this form. Alternately, you may download a form you can print, fill out, and send to us.

(Born Free USA helps defray veterinary costs associated with non-target trapping incidents with our Trapping Victims Fund.)

* designates a required field.

Information about you

* First name:
* Last name:
* Address 1:
Address 2:
* City:
* State or province:	Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Federated States of Micronesia Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
* Zip/postal code:
* Email address:
Telephone:

Information about the incident

* Date of incident:
* Species of victim:
Victim's name:
Extent of injury: (check all that apply)
swelling cut death	bruising broken bones other
If Other, please describe (500 max. characters):
If amputation, name appendage(s):
Estimated time in trap:
Type of trap:
steel-jaw leghold conibear other	snare unknown
If Unknown or Other please describe (500 max. characters):

Location of incident

* City
* State:	Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Federated States of Micronesia Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
* Zip/postal code:
Describe area: (near homes? on trail? near campground? etc.) (500 max. characters)
Name of attending veterinarian or doctor:
Treatment description (500 max. characters):
Treatment cost:
Additional notes about incident (500 max. characters):
To which agency was this incident reported (if any)?
Was the trap owner found?	Yes No
Was owner charged with a violation (500 max. characters)?

Are you willing to help us end trapping?

On the behalf of, or in cooperation with, Born Free USA, would you or anyone associated with this incident be willing to:

Testify about your incident at a local city or county hearing? Yes No

Talk to the media about your incident? Yes No

Tell your story to Born Free USA members in our magazine, blog or direct mail? Yes No

If Yes, please list names and contact information: (500 max. characters)

List any additional details you feel would be helpful: (500 max. characters)

Are you interested in applying to receive assistance from our Trapping Victims Fund? Yes No

Please send copies of any newspaper articles and photos regarding this incident to us by emailing info@bornfreeusa.org or writing to:

Trapping Incident
c/o Born Free USA
P.O. Box 22505
Sacramento, CA 95822

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