MFHS OPEN INTAKE COMPLAINT FORM

CONFIDENTIAL COMPLAINT FORM

Please provide as much brief, factual information as possible.

*Indicates required information. Please provide as much of the * information as possible.

Your name, contact information, the address where the animals are located, description of the animals and your complaint are required.

* Indicates required field

Date: *

Time: *

Your Name: *

First

Last

Would you come forward as a witness if needed? *

Yes No

Photos/Video Attached: *

Yes No

Note: Email current photos and short video to [email protected]. Please provide the date and time the photos/video were taken and a brief description of each.

Witness Status: *

1st Hand Account 2nd Hand Account Other

If you chose other in witness status, please state here: *

Relationship to AV: *

Neighbor Friend Relative Other

If you chose other in Relationship to AV, please state here: *

Your Contact Ph (mobile/landline/wk): *

Email Address: *

Your Street Address: *

City: *

State: *

Zip: *

County: *

Your DOB (month/day/year): *

Your DL#: *

State DL Issued: *

Name of Alleged Violator/s (AV): *

AV Phone Number: *

Street Address of AV/Location of Animal(s): *

City: *

State: *

Zip: *

County: *

AV DOB (month/day/year): *

AV DL#: *

State DL Issued: *

AV Address if different than where animals are located: *

City: *

State: *

Zip: *

County: *

Please describe why you are contacting us today: *

IF YOU WISH TO PROVIDE A MORE DETAILED COMPLAINT, PLEASE REVIEW AND SELECT THE APPROPRIATE RESPONSES (Select as many as needed. Please provide your witness statement and any evidence supporting your complaint, which may include, but may not be limited to: photos, short video, veterinary records.)

Upload supporting documents here: *

Max file size: 20MB

Suspected Violations of MN Animal Cruelty Statute 343.21 *

Subdivision 1. Torture. No person shall overdrive, overload, torture, cruelly beat, neglect, or unjustifiably injure, maim, mutilate, or kill any animal, or cruelly work any animal when it is unfit for labor, whether it belongs to that person or to another person. Subd. 2. Nourishment; shelter. No person shall deprive any animal over which the person has charge or control of necessary food, water, or shelter. Subd. 3. Enclosure. No person shall keep any cow or other animal in any enclosure without providing wholesome exercise and change of air. Subd. 4.Low feed. No person shall feed any cow on food which produces impure or unwholesome milk. Subd. 5. Abandonment. No person shall abandon any animal. Subd. 6. Temporary abandonment. No person shall allow any maimed, sick, infirm, or disabled animal to lie in any street, road, or other public place for more than three hours after receiving notice of the animal's condition. Subd. 7. Cruelty. No person shall willfully instigate or in any way further any act of cruelty to any animal or animals, or any act tending to produce cruelty to animals. Subd. 8. Caging. No person shall cage any animal for public display purposes unless the display cage is constructed of solid material on three sides to protect the caged animal from the elements and unless the horizontal dimension of each side of the cage is at least four times the length of the caged animal. The provisions of this subdivision do not apply to the Minnesota State Agricultural Society, the Minnesota State Fair, or to the county agricultural societies, county fairs, to any agricultural display of caged animals by any political subdivision of the state of Minnesota, or to district, regional or national educational livestock or poultry exhibitions. The provisions of this subdivision do not apply to captive wildlife, the exhibition of which is regulated by section 97A.041*. Subd. 8a. Harming a service animal. No person shall intentionally and without justification do either of the following to a service animal while it is providing service or while it is in the custody of the person it serves: (1) cause bodily harm to the animal; or (2) otherwise render the animal unable to perform its duties.

*Link to 97A.041.

Suspected Violation of 346.38 EQUINES.
Subdivision 1. Definition. "Equines" are horses, ponies, mules, and burros. *

Subd. 2. Food. Equines must be provided with food of sufficient quantity and quality to allow for normal growth or the maintenance of body weight. Feed standards shall be those recommended by the National Research Council. Subd. 3. Water. Equines must be provided with clean, potable water in sufficient quantity to satisfy the animal's needs or supplied by free choice. Snow or ice is not an adequate water source. Subd. 4. Shelter. Equines must be provided a minimum of free choice protection or constructed shelter from adverse weather conditions, including direct rays of the sun in extreme heat or cold, wind, or precipitation. Natural or constructed shelters must be of sufficient size to provide the necessary protection. Constructed shelters must be structurally sound, free of injurious matter, maintained in good repair, and ventilated. Outside exercise paddocks for equines do not require separate constructed shelter where a shelter is accessible to the equine on adjacent or other accessible areas of the property provided that equines are not kept in outdoor exercise paddocks during adverse weather conditions. Subd. 5. Space and cleanliness requirements. Constructed shelters except for tie stalls must provide space for the animal to: (1) roll with a minimum danger of being cast; or (2) easily stand, lie down, and turn around. Stalls must be cleaned and kept dry to the extent the animal is not required to lie or stand in fluids. Bedding must be provided in all stalls, kept reasonably clean, and periodically changed. The nature of the bedding must not pose a health hazard to the animal. Subd. 6. Exercise. Equines must be provided opportunity for periodic exercise, either through free choice or through a forced work program, unless exercise is restricted by a licensed veterinarian. Subd. 7.Hoof care. All equines must have their hooves properly trimmed periodically to prevent lameness. Subd. 8. Transportation. A vehicle used to transport an equine must have a floor capable of supporting the animal's weight safely. Floors must be of nonskid construction or of nonskid material sufficient to provide the animal with traction while in transport. A minimum of 12 inches must be allowed between the withers of the largest equine and the structure above the animal while it is in a natural standing position. Sturdy partitions must be provided at a minimum of approximately every ten feet inside the vehicle. Interior compartments of transporting vehicles must be of smooth construction with no protruding or sharp objects and must provide ventilation. Food and water must be provided in sufficient quantities to minimize stress and maintain hydration.

Suspected violation of MN Statute 343.40 Dog Houses

Subdivision 1. In general. A person in charge or control of any dog which is kept outdoors or in an unheated enclosure shall provide the dog with shelter and bedding as prescribed in this section as a minimum. *

Subd. 2. Building specifications. The shelter shall include a moisture proof and windproof structure of suitable size to accommodate the dog and allow retention of body heat. It shall be made of durable material with a solid, moisture proof floor or a floor raised at least two inches from the ground. Between November 1 and March 31, the structure must have a windbreak at the entrance. The structure shall be provided with a sufficient quantity of suitable bedding material consisting of hay, straw, cedar shavings, blankets, or the equivalent, to provide insulation and protection against cold and dampness and promote retention of body heat. Subd. 3. Shade. Shade from the direct rays of the sun, during the months of May to October shall be provided. Subd. 4. Farm dogs. In lieu of the requirements of subdivisions 2 and 3, a dog kept on a farm may be provided with access to a barn with a sufficient quantity of loose hay or bedding to protect against cold and dampness. Subd. 5. Zoning. All shelters required by this section shall be subject to all building or zoning regulations of any city, township, county, or state.

If animal is being treated cruelly, is abused, neglected, or tortured, please describe here: *

Choose any that apply *

Lack of or no shelter Lack of or no potable water Lack of or no food/poor quality Poor condition of animals/deceased, sick or injured, matted fur, lack of or no vet care

Poor condition of animals/deceased, sick or injured, matted fur, lack of or no vet care. Describe here: *

Choose any that apply *

Unkempt kennel/housing (excessive feces/urine) Lack of Exercise/Stuck in kennel or crates for lengthy periods of time Environmental Conditions (temps are too hot or cold/bad weather/hazardous conditions) Too many animals/hoarding Suspected puppy/pet mill Community cat assistance/TNR Other

If you chose other, please describe *

If you checked the any of the boxes above, please use this space to provide additional information: *

ANIMAL DESCRIPTIONS

Attach all supporting documents, photos and video. Provide brief description and time/date for each

Upload supporting documents here: *

Max file size: 20MB

Description of Animal(s):

How many animals? *

What type (cat/dog/horse/pig/goat/sheep/cow/rodent/reptile/bird/fish/wildlife/other) Describe: *

Breed *

Color: (brn/blk/white/orange/striped/spots/other) Describe: *

Coat: (short/medium/long/curly/other) Describe: *

Sex (M/F/unknown): *

Names of Animal(s): *

Spayed/Neutered/Unaltered/Unknown: *

Describe Body Type (thin, normal, obese) (ribs, backbone/spine, hip bone showing/protruding)? (Attach Body Scoring/Field ID Report/Intake Report) *

Condition of Animals (coat condition of animal, clean/matted/dirty/missing hair/unkempt/other)
Describe: *

Describe Suspected Injuries or Possible Illness (visible limping/open wounds/bleeding/swelling/bruising/broken bones/infection/labored breathing/nasal or eye discharge/other) Do not diagnose/provide what you observed: *

Describe Temperament (friendly/aggressive/scared/timid/stand-offish, etc.): *

Veterinary/Medical (attach veterinary records if available)

UTD on Vaccinations? Yes/No/Unknown: *

When last veterinary visit? (attach records): *

Max file size: 20MB

Is the animal used for medical purposes (trained therapy animal/emotional support/unknown)? *

Exercise

-Do the Animals Get Exercise? How? For how long? Unknown: *

PROPERTY DESCRIPTION

Attach supporting documents/photos/property records/aerial view *

Max file size: 20MB

Describe Overall Environment and Where Animals are Kept:

Describe Cleanliness of Interior/Exterior:

Interior

Dirty/Clean/Organized/Messy?
Describe: *

Are Feces/Urine/other bodily fluids (Human/Animal/Unknown) present and how much? *

Exterior

Dirty/Clean/Organized/Messy?
Describe: *

Are Feces/Urine/other bodily fluids (Human/Animal/Unknown) present and how much? *

Describe Hazards or Dangerous Materials:

Are there any dangerous or sharp objects/anything that could be hazardous to humans or animals? Y/N/U Describe: *

Are there hazardous chemicals present? Y/N/U
Describe: *

Are there weapons on the property? Y/N/U Describe Firearms or other weapons: *

Are any of the following present on the property (enclosures/dog houses/kennels/shelters/barn/out building/lean to/fencing/none/unknown) Describe materials used (wood/metal/sheetrock/plastic/other)? Describe size and condition (new/newer/old/falling down/good or bad/other/unknown): *

Describe Air Quality (smells?):

Do the animals get fresh air? Y/N/U How (Air conditioning/Open windows/Ventilation/Kept out of doors/other)? Are there fans? Y/N/U How many? Filters? Y/N/U How many? *

To your knowledge, has law enforcement been to this property? Y/N/U If so, how many times? Describe: *

Are you aware of any illegal drugs or drug usage? Y/N/U Describe: *

Are you aware of any substance abuse? Y/N/U Describe: *

Are you aware of any violence or abuse? Y/N/U Describe: *

Restraining orders or orders for protection? Y/N/U Describe: *

Describe any suspicious behavior (if any): *

Are you aware of possible mental illness? Y/N/U Describe: *

Is the AV under the care of a physician? Y/N *

Are you aware of a social worker’s involvement with the AV or the AV’s family? Y/N/U Describe: *

Describe main dwelling and any unique features of the property:

Color of house/trim: *

Attached or detached garage: *

Outbuildings (how many and describe): *

Describe Vehicles (Cars/Trucks/Mobile Home/Camper/Tractors/ATVs/Boats, etc.): *

Are they operational? *

What vehicles do you see coming and going? *

Does anything stand out about this property? Describe something that sets this property apart from other neighboring properties: *

PERSONNEL INVOLVED IN CASE

If you have contacted any other organization pertaining to this complaint, please include that information below.

Law Enforcement Dept: *

Department Phone Number: *

Officer Name: *

Officer Phone Number *

Badge #: *

Officer Email: *

Case Number, if available: *

Animal Control Officer Name: *

Animal Control Phone Number *

Animal Control Email *

Rescue/Shelter: *

Rescue/Shelter Phone Number: *

Rescue Personnel Name: *

Rescue Personnel Email *

Rescue Personnel Phone Number: *

Veterinary Clinic: *

Veterinary Clinic Phone Number: *

Veterinarian Name: *

Veterinarian Email: *

Board of Animal Health | Ph: Main 651-296-2942

Direct *

Email *

Other BAH Rep Name: *

Other Phone Number *

Board of Veterinary Medicine | Ph: Main 651-201-2844 | Email: [email protected]

Rendering: Don Myren, Ag Advisor | Ph: 218-343-8921 | Email: [email protected]

Human Services Dept: *

Human Services Dept Direct Phone Number: *

Case Worker Name: *

Case Worker Email: *

City or County Attorney Name: *

City or County Attorney Phone Number: *

City or County Attorney Email: *

Government Officials (City Planner): *

Government Officials Phone Number: *

Government Officials Email: *

Fire Department: *

Fire Department Phone Number: *

Fire Department Email: *

Other Organization/Personnel: *

Other Organization/Personnel Phone Number: *

Other Organization/Personnel Email: *

Submit

Address:
PO Box 416
Anoka, MN 55303

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Phone:
612.866.8663
E-mail:
[email protected]

CONFIDENTIAL COMPLAINT FORM

ANIMAL DESCRIPTIONS

​Description of Animal(s):

​Veterinary/Medical (attach veterinary records if available)

​Exercise

PROPERTY DESCRIPTION

Describe Overall Environment and Where Animals are Kept:

PERSONNEL INVOLVED IN CASE

ABOUT MFHSOUR WORKOUR MISSIONFAQsDONATECAMPAIGNS employer GIVING​legacy gifts​

Description of Animal(s):

Veterinary/Medical (attach veterinary records if available)

Exercise

ABOUT MFHS
OUR WORK
OUR MISSION
FAQs

DONATE
CAMPAIGNS
employer GIVING
legacy gifts