Date of Attack    

Victim
First Name			Last Name
Address
City		State		Zip
Telephone		email
Date of Birth		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

Victims Recovery,	Yes	No	Photographs of injury:	Yes	No
Photographers 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