Victim

First Name
Last Name

Address

City
State Zip

Telephone
Country

Date of Birth

email

Occupation

Height
                  Weight

Sex Male       Female Color of exposed skin

Longitude   Latitude

Body fully clothed? Yes No

Type and color of clothing

Activity at time of attack

Describe type and color of equipment used in this activity

Victim's Recovery
Yes No Photographs of injury: Yes No

Photographer's Name

Address

Hospital Name

Address

Phone

Attending Physician

Address

Phone

Species of shark

Identified by

Number of sharks involved

Description of shark:

Witness(es)
Name	Address	Phone

Length of time in water prior to attack

Location of attack

Distance from shore Depth of attack Time of day

Water Temperature Air Temperature Estimated Taken

Weather conditions

Sea conditions Water visibility

Water depth at attack location

Description of ocean floor at attack location

Deep water channel or drop off at attack location Yes No

If yes, distance from attack location

Kelp present at attack location Yes No

Distance from kelp

Amount and location of kelp

Were marine mammals present at or near attack location Yes No

If yes, location, number, and species of animals:

Unusual behavior of fishes, birds or marine mammals prior to attack Yes No

If yes, type of animal and behavior observed:

Collecting of marine animals prior to attack Yes No

Type of animals collected prior to attack:

Number of marine animals collected prior to attack
Method of collection and length of time
Aware of sharks presence prior to attack:	Yes No
Aware of prior attacks at the same location:	Yes No
Sharks sighted at this location prior to your attack:	Yes No
If yes, date of previous sighting
Witness to previous shark sighting

Attack description: Describe in detail the movement and behavior of the shark and victim prior to, during, and following the attack. Describe rescue, nature of injury, emergency and subsequent medical treatment

I understand that upon submission of this form I will have donated the above data to Ralph S. Collier and/or the Shark Research Committee for their ongoing white shark research projects including white shark/human interactions from the Pacific Coast of North America. I voluntarily donate this information to further our knowledge of the white shark and its interactions with humans.

First Name
Last Name

Address

City
State Zip

Telephone

email

The material contained on this website is shared as a public service and to further the scientific goals of the Shark Research Committee. All text and images on this website are the exclusive property of the Shark Research Committee. Information on this website may be used for private study, but may not otherwise be published, duplicated, or modified in any way without the prior written permission of Ralph S. Collier.