Dog Attack Form


Privacy & Personal Information Protection Notice

Purpose of collection: We are collecting your personal information so that Council can investigate your report of a threatening dog or dog attack. Intended recipients: The intended recipient of the information is Kiama Municipal Council. Supply: While the supply of this information is voluntary, the personal information you provide will enable Council to carry out the request.  Access/Correction: You can access the personal information and it may be available to third parties in accordance with the Government Information (Public) Access Act and Council’s Privacy Management Plan. You may make an application for access or amendment to personal information held by Council. We will consider any such application in accordance with the Privacy and Personal Information Protection Act 1998. Storage: Kiama Council is the agency that holds the personal information. Council may be contacted on (02) 4232 0444 or by email to   or at 11 Manning Street Kiama NSW 2533. Your contact details may be used to update Council’s Name and Address Register that we may use to contact you regarding any other Council matter. Kiama Council’s Privacy Policy can be viewed at

Complete the below form to notify Council of a threatening dog or a dog attack.

Details of victim

Details of the attack

Description of attacking dog


Details of the attack

Were you treated by a doctor?
Did you receive a medical certificate?
Have you reported to the attack to the police?

Name and address of any witnesses

Victim statement

Statements made by you on this form may be used in a court of law. 

By submitting this form you agree that you are willing to give evidence in court if necessary.

Please read all statements made on this form before you submit it.

Please attach copies of any medical certificates, doctor's report, or other relevant documents relating to the incident.


Mandatory field(s) marked with *