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—DLORIDA GAME & FRESH WATER FISH COMMISSION SS cour LB | 27 | cEMPLATIE 30, Ma les: escape [| bite fi’ injury () other 1 REPORTING INSPECTOR: _C. Denes (COMPLAINT OFFICER(S):__¢. Dens VERIFICATION "TYPE: class 1) 20 34 NATIVE BxorIcy VISOAL SIGHTING EY GFC PERSONNEL REPTILE: VENOMOUS NONVENOHOUS [} a (0 INFORMATION FROM "THE PUBLIC FIsi ) BIRD O MAMMAL f° OTHER [] Rae __|Neber/Species of animals involved: | Aaa i GE pee Phone Ab OTHER: z LOCNTTON GF TNCTDANE! ~~. STTUATIONAL ORIGIN: (] relessed —LOCHTTON OP ESCAPE/RELEASE peas {] escaped = ORNER'S Name: any unknown Threat to public: J yes Permit: J) no fh yes # | f Elcwcgncl CBee ___4 yes: Public [] GRC employee {] AC officer {] Police [) other J Permittee/enployee ff Permittee relative] Permittee friend) at a soaks Ped eat ek backd Ledge Cee we DISPOSITION srarus: [ animal(s) still Loose animal destroyed Q animal captured {] animal returned to omer {] seized/placed: ACHION TAREN: citation(s), Warning(s) V6. Time Miles 7 snares (] traps () () chemical: bait (] projectile () OQ data card completed ae a REVIMNED BY: CAPTIVE WILDLIFE INCIDE! /BITE/ESCAPE NARRATIVE 1. TYPE BITE, 2. IBE # 1726 3, RESPONDING OFFICER (8) SHANNON WIYDA 4, INCIDENT DATE 2/10/08 6. ANIMAL TYPE INVOLVED TIGER 7, LOCATION OF INCIDENT PALM BEACH ZOO 9. OWNER’S NAME, PALM BEACH ZOO PERMITTED PALM BEACH ZOO-KEITH LOVETT 10. INJURIES BRIEF DESCRIPTION FINGER TIP BITTEN (1CM) VICTIM'S NAME SUSIE NUTTALL DOB/AGE 10/16/82 MEDICAL REPORT ATTACHED NO (rv? YES OR NO} MEDICAL DETAILS BONE FILED, STICHES AL. ACTION TAKEN -REPORT TAKEN 12, DISPOSITION STATUS -CLOSED 13. ANIMAL CAPTURED —_NA (ry? YES,NO.OR Na) 14, INCIDENT NARRATIVE ‘On February 10, 2008 a keeper employed by Palm Beach Zoo, was bitten by a Susie Nuttall (keeperivictim) and Amanda Haug (assistant curator) were training two male tigers (Mata & Rimba 2,8yrs old) in their night house. ‘The keepers were training the two tiger’s commands; sit, paw up, ete. The tigers were separated, in neighboring cages and each keeper worked with their own tiger adjacent to each other, Ms. Nuttall was in surgery and not available for an interview at the time of my investigation, Ms. Haug provided the following events. Ms. Nuttall was training Mata in a low/squatting position. While training, keepers are to provide an instant reward. The rewards are fed with a flat palm or tube shaped meat, All other non training foods are introduced through a food chute, Ms. Nuttall was providing a reward when Ms. Hang heard her make a noise, Ms. Haug ‘went to Ms. Nuttall to see if she was all right and observed Ms. Nuttall’s right middle finger tip had been bitten. Ms. Nuttall was sent to the emergency room immediately. On February 11, 2008, Ms Nuttall had hand surgery. The surgery consisted of smoothing the bone on the tip of her finger and stitehes, The injury was denoted with a depth of Lem. All large carnivore trainers are provided with the Palm Beach Zoo protocol (attached), trained for numerous documented hours, and are always accompanied by another keeper. The victim, Ms. Nuttall had 8 months experience at the Palm Beach Zoo and a year of experience at another facility. The assistant curator present during the incident, ‘Ms. Haug, has 5.5 years experience at the Palm Beach Zoo. Although this was an aceident by the victim, hand feeding has been proven to bea safety hazard. Palm Beach Zoo's large carnivore reward protocol shall be re-evaluated, At is time, PBZ, is no longer allowing hand feeding. No citations were given at this time, Tae- 022 oe FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION wee DIVISION OF LAW ENFORCEMENT i ee INCIDENT SUMMARY REPORT Nad” 7 JuveNILe BY oricinat (C1 SUPPLEMENT REPORT # On May 19" |, Investigator Jon Garzaniti, was made aware of an incident that occurred at the Palm Beach Zoo. The Assistant Zoo Director, Keith Lovett, reported that an employee entered a restricted area near the tiger exhibit to remove a DVD player. The employee, Brandon Dana, slipped while removing the DVD player, and fell with his back against the mesh cage. The tiger scratched Mr, Dana’s back at this time, causing minor injuries. Mr. Dana did not nave permission fo enter the restricted area. The incident occurred on May 17", but was not reported by the employee until the 18° On May 19" | interviewed Mr, Lovett at the Palm Beach Zoo. | collected a sworn written statement from him at this time, which he had previously filled out documenting the incident, (Mr, Lovett stated that Mr. Dana reviewed that statement and agreed the statement was accurate. | also photographed the area where the incident occurred. The GPS coordinates where the injury occurred is N 26 40 10, W080 04 184. ‘On May 20" | interviewed Mr. Dana at his residence. He provided a recorded statement of the incident. | provided him with the statement ! received from Mr. Lovett, and asked him to review it for accuracy. He stated that he had already reviewed it and that he did not see any discrepancies with i. He went on to say that he “didn't say it was the zoo’s fault”, and that he thought the tiger was not in his enclosure at the time he entered the restricted area. | photographed the injuries Mr. Dana received at this time as well, | tumed the information | gathered over to Investigator Wiyda, who completed the report. This was done as | had two weeks of scheduled paternity leave starting the following day. There is nothing further to report at this time. Nanbo of vestpeve Miles ‘Number vestigate Vessl Haus Tela Number Ivete Hours 4 ees 20 = Photograph By in Jon Garzanifi sec a S/I9/44 and 5/2014 | ewear the above statment scored ed toto the best of iy inowedge ard bee ‘Swom lo and ubsibed blows me, te undesirably tis lay ok Eee ee [ere seeese see eee M727 6isitt Oifors Spans oF ot ea ta OTT 7 soap yo the Cob Nt, of Law Exoroorion Ooo Sepatue Jon Garzaniti : wae watt ices Wane oF Ageney Phone/ CeliProne: __( 661) 670 - 5530 1 ( Rear 6 Paap FFWCDLE 045A (0808) COfflon's Slgnatre (tnt ready ons page) cee Page tof DIVISION OF LAW ENFORCEMENT SWORN WRITTEN STATEMENT FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION Se ri Date and time statement received: _May 19,2011, 4:00 pin ‘Coss number: _FWSA-11-OFF-2966 Location where statement was glvon:_Palm Beach Zoo Tiger Exhibit Name of person giving staiement _ Keith Lovett a Dur _11g0-513-70-452.0 ee faa DOB: _12/12/70 ‘Adress of person giving statement : _12939 175th Ra N Jupiter, FL 3347 Home Phoned, _( 561) 743 — 6491 Work Phone# _( 581.) 833 - 7130 _ Gell _( 561.) 719 — 1594 STATEMENT. Background Information: Mr. Brandon Dana has been employed as a maintenance department employee at the zoo since June 2010, During his tenure at the zoo Mr. Dana has been regularly instructed by the Zoo's Director of Operations (now retired) Rick Forbes, Maintenance Supervisor Eric Cassidy, newly hired Maintenance and Facilities Manger (MFM) Sam Bauer, and the Assistant Zoo Director (AZD) Keith Lovett on policies and procedures preventing direct access to dangerous animals residing at the zoo. A teemphasis of these policies was performed by the Maintenance and Facilities Manger and Assistant Zoo Director over the last couple weeks following an incident where Mr. Dana violated zoo polioy regarding, access to restricted animals. On Sunday Mayi5, 2011, zoo maintenance department technicians Mr. Frank Cablik and Mr. ‘Andre Michaud worked under direction of the zoo's AZD to install a television and DVD player in front of the zoo's tiger exhibit. Those items were installed to facilitate an upcoming press conference announcing the birth of tiger cubs and to allow public viewing of video showing the tiger birth. As part of the AZD's direction to employees, significant emphasis was placed on reminding staff that the placement of the clestronio equipment would be in a restricted area adjacent to dangerous animals and that no work was to be performed without the supervision and prior notification of the need for access to the zoo's lead keeper of the tiger area, Nancy Nill. ‘The electronics were installed on Sunday with proper notification and supervision of animal care staff and without incident. The AZD also reiterated the need for safety in this restricted area and reminders of the notification policy was directed to Mr. Cahlik and Mr. Michaud on Monday morning, May 16, 201 1, duting the press conference by the AZD. ‘On Tuesday May 17, 2011, Mr, Michaud with Mr, Dana as a helper contacted Ms, Nill to provide access to the elect onies in the restricted area. Ms. Nill opened the restricted area to allow the work to be performed and reiterated the need to stay away from the exhibit mesh. During this work being performed by Mi. I lichaud, br. Dana dis :overed a loose fence picket and asked Ms. Nill permission to climb over a section of the fence to allow him the opportunity Ewen E one sams Dana t aft to fix the picket. Ms, Nill reiterated to Mr. Dana that she was only allowing permission because she was present to supervise the work and that he was not to ever climb the tiger barrier fence without permission from the appropriate staff, ‘The electronics and picket repair work was performed without issues. Incident; At approximately 4:30 pm on Tuesday May 17, 2011, the zoo's MFM asked employee Mr. Cahlik to inform fellow employee Mr. Michaud to remove the DVD player from the restricted area for the evening. After receiving instruction from the MFM, Mr. Cablik inquired to Mr. Dana the location of Mr. Michaud. Mr. Dana informed Mr. Cahlik thet Mr. Michaud was dealing with the clean up of broken glass in the west side parking lot. Mr. Dana asked Mr. Cablik why he needed Mr. Michaud and Mr. Cahlik relayed the instruction received from the MFM regarding the removal of the DVD player. Upon hearing the instruction relayed to Mr. Cablik from the MEM, Mr, Dana questioned why Mr. Michaud had to perform this work. Mr. Cablik told him that the MFM wanted it performed by Mr. Michaud because he was trained on the installation of the equipment. According to Mr. Cablik, Mr, Dana stated that " a baby could do this work and it only required the removal of three wires". After this discussion with Mr, Cablik and without the approval of the MEM or any other zoo supervisor Mr. Dana traveled to the tiger exhibit to remove the DVD equipment, Once he arrived at the tiger exhibit, Mr. Dana did not call Ms. Nill or any other animal department employee responsible for the tigers, did not inquire with any staff or check for himself to see if the tiger was still on exhibit, and since he did not have a key to the barrier fence gate he jumped over the barrier fence in order to access the DVD player. During his removal of the equipment Mr. Dana came too close to the exhibit fence with his back and the tiger on exhibit jumped on the mesh and was able to soratch Mr. Dana's back resulting in moderate injury. ‘After the injury, Mr. Dana who has had workplace injuries during his employment at the 200 and is aware of the zoo's policy requiring the notification of injury to z00 management and the completion of a work place injury form, did not inform any management or other staff members of his injury and did not complete the required paperwork. Later that evening without the notification to the 200 of the injury, Mr. Dana sought treatment for his injuries at a local hoypital, When later question by the AZD about whether Mr. Dana had informed the hospital of the nature of his injury, Mr. Dana stated that "I just told thom it was an animal injury and I refused to fill out a requested incident report at the hospital." When asked by the AZD, Mr. Dana stated that he did not inform the hospital that he was involved in a workplace injury or that the injury occurred at the zoo. Due to the extent of the bruising and contusions on Mr. Dana's back, the hospital instructed Mr. Dana to refrain from work the following day. Mr. Dana texted in sick to the MFM on the morning of Wednesday May 18, 2011, but did not divulge the nature or cause of his injury. ‘The MFM then proceeded to call Mr. Dana and discuss the nature of his illness and whether he needed to be seen by a doctor and Mr. Dana said "he was sick, had gone to the hospital and received antibiotics, and it was not a big deal”, Went = ana foainay Pane 263 Upon returning to work on Thursday May 19, 2011, Mr. Dana approached the MFM and fellow worker Mr, Paul Bedard. During a brief discussion where the MFM questioned how he was feeling and inquired further about his illness, Mr, Dana stated that he did not want to tell the MFM and really needed to talk to "Keith" the zoo's AZD. The MFM questioned whether he had fallen off'a ladder or some type of related injury and Mr. Dana divulged to Mr. Bedard and the MFM that he was "hit from behind by the tiger". Upon hearing this information, the MFM instructed Mr. Dana to proceed to the zoo hospital to discuss the incident with the AZD and the MFM immediately contacted the AZD by text to inform him of Mr. Dana's pending arrival. Soon after arriving at the hospital, the AZD had a series of meeting with involved staff to discuss the details of the incident. Those staff members included Mr, Dana, Mr. Michaud, Mr. Eric Cassidy, and Ms. Nancy Nill. Additionally, Mr. Cahlik was reached by phone to confirm the details of the incident, During the series of meetings, Mr. Dana confirmed that he entered the restricted tiger area without permission, that he knew he was required to call the lead keeper prior to entering the area, that he was aware that he did not have a key to the restricted area because he was not permitted entry to this area without permission, and that Ms. Nill did informa hhim previously in the day that he was never to hop the tiger fence without permission. ‘Additionally Mr, Dana acknowledged that he was aware of the zoo policy regarding reporting ‘workplace injuries and that he purposefully violated these policies to avoid "getting in trouble” T have 16d this statement and initialed al corrections. fully undersiand its entre contents and solemnly swear (or affirm) that tis true and SUBSCRIBED and sworn to (oy/affirmed) before Ve: eID me, a law enforcement authorized to Sottae ‘of Officer administer oaths pursuant to Florida Statute o La 117.10. Don GAe2Anv: —— Name of Officer (Pr AMIN ER fnmnR Pana Bara DIVISION OF LAW ENFORCEMENT FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION ae CAPTIVE WILDLIFE INJURY BITE ESCAPE FORM breadky peannusk Hf (oe / DATE REPORTED: 5/19/2011 REPORT DATE: _ 5/24/11 INCIDENT DATE: 5/17/2011 COMPLAINT OFFICER ($):GARZANITI VERIFICATION TYPE: VISUAL ‘ANIMAL TYPE INVOLVED: TIGER Name: _BRANDON DANA. Address: _7131 HIGHRIDGE RD Phone: ___561-502-4975 BOYNTON BEACH FL Clty State Zip CIOTHER LOCATION OF INCIDENT: PALM BEACH ZOO LATILONG: FLOCATION OF ESCAPE/RELEASE: NIA SITUATIONAL ORIGIN: NIA Threat to public? [J] Yes XNo [] NA Permitted: X OWNER'S Name: Phone: ( INCIDENT NARRATIVE: ‘On May 19” 2011, | received a call from the assistant director of the Pi Zoo, Keith Lovett. He stated that he was just advised that one of his maintenance staff was injured by a tiger on May 17th. The employee Brandon Dana, has boon employed with the zoo since June 2010. Mr. Lovett stated on May 17”, the victim Brandon Dana, Jumped the public barrier to remove a DVD player, Mr. Dana does not have the key to the barrier fence as he is not to have access to these restricted areas. He has been instructed of this on previous occasions, most recently 5/15/11 while installing the DVD player. At this time he was also instructed to have animal staff present at all times when in restricted areas. Mr. Dana was also not requested to remove the DVD player, another employee was instructed to do so, and Mr. Dana took it upon himself to remove the DVD player alone. Mr. Dana did not follow verbal protocol to contact animal staff before accessing the restricted area. (Mr. Lovett stated they are planning ‘on making this a written policy) Mr. Lovett stated Mr. Dana entered the restricted area and the tiger jumped on the mesh of the enclosure and caused minor injuries to Mr. Dana’s back. (On May 20", Mr. Dana reviewed Mr. Lovett’s statement and did not find any discrepancies. (Statement attached ) Mr. Dana described the incident to Investigator Garzaniti, Mr. Dana stated he jumped the barrier fence to remove the DVD player. While removing the DVD player, he slipped and his back leaned against the tiger enclosure. The tiger ran and jumped on the enclosure, this pushed Mr. Dana into the barrier fence. He examined himself and did not find any substantial injuries. He left the area, packed his stuff and went home. He did not advise anyone of the injury, this is violation of zoo policy. (attached) Mr. Dana later went to the hospital for medical treatment. He did not advise the hospital that the injuries were caused by a tiger. Mr, Dana was treated and released the same day and was advised to take one day off of work. He called in sick the next day and still didn’t advise of his injury. Upon returning to work the 19" of May he advised of his injuries. | Brapiz FWODLE 603 (04/06) fucornbed on I. FWODLE 09 64I06) INJURIES: ‘Scratches, slight puncture, and contusions to back VICTIM'S Name: _BRANDON DANA. DOBVAGE: _ 11/20/60 Address: _7131 HIGHRIDGE RD BOYNTON BEACH FL City State Zp Medical Report attached? [] Yes X No | Medical det ACTION TAKEN: DISPOSITION STATUS: = RT ANIMAL CAPTURED. | CAPTURE METHOD: COMMENTS: NA’ NA SIGNATURE: Sheree REGION: _SRA MILES: _50 TIME: 6 INVESTIGATOR: _Shannon Wiyda M723______REVIEWED BY: _ at FWCOLE 609 (0408) FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION DIVISION OF LAW ENFORCEMENT SWORN WRITTEN STATEMENT Date and time statement received: _May 19, 2011, 4:00 pm Case number: _FWSA-11-OF F-39896 Location where statement was given: _Pelm Beach Zoo Tiger Exhibit Name of person giving statement: _Kei Lovett sees DL#: _L130-513-70-452.0 Doe: 12/12/70 Address of person giving statement : _12939 175th Rd. N Jupiter, FL 33478 : Home Phone #: _( $61) 743 - 6491 Werk Phone _( 551) 833 — 7130 Cell# _( 561.) 719 - 1594 Background Information: Mr. Brandon Dana has been employed as a maintenance department employee at the zoo since June 2010. During his tenure at the zoo Mr. Dana has, been regularly instructed by the Zoo's Director of Operations (now retired) Rick Forbes, Maintenance Supervisor Eric Cassidy, newly hired Maintenance and Facilities Manger (MFM) Sam Bauer, and the Assistant Zoo Director (AZD) Keith Lovett on policies and procedures preventing direct access to dangerous animals residing at the zoo. A reemphasis of these policies was performed by the Maintenance and Facilities Manger and Assistant Zoo Director over the last couple weeks following an incident where Mr, Dana violated zoo policy regarding access to restricted animals. On Sunday May15, 2011, zoo maintenance department technicians Mr, Frank Cahlik and Mr. Andre Michaud worked under direction of the zoo's AZD to install a television and DVD player in front of the zoo's tiger exhibit. These items were installed to facilitate an upcoming press conference announcing the birth of tiger cubs and to allow public viewing of video showing the tiger birth. As part of the AZD's direction to employees, significant emphasis was placed on reminding staff that the placement of the electronic equipment would be in a restricted area adjacent to dangerous animals and that no work was to be performed without the supervision and prior notification of the need for access to the z00's lead keeper of the tiger area, Nancy Nill. The electronics were installed on Sunday with proper notification and supervision of animal care staff and without incident. The AZD also reiterated the need for safety in this restricted area and reminders of the notification policy was directed to Mr. Cablik and Mr, Michaud on Monday morning, May 16, 2011, during the press conference by the AZD. On Tuesday May 17, 2011, Mr, Michaud with Mr. Dana as a helper contacted Ms. Nill to provide access to the electronics in the restricted area. Ms. Nill opened the restricted area to allow the work to be performed and reiterated the need to stay away from the exhibit mesh, During this work being performed by Mr. Michaud, Mr. Dana discovered a loose fence picket and asked Ms. Nill permission to climb over a section of the fence to allow him the opportunity FWCDLE 208 (09/08) Page tof4 is to fix the picket. Ms. Nill reiterated to Mr, Dana that she was only allowing permission because she was present to supervise the work and that he was not to ever climb the tiger barrier fence without permission from the appropriate staff, The electronics and picket repair work was performed without issues, Incident: At approximately 4:30 pm on Tuesday May 17, 2011, the z0o's MFM asked employee Mr, Cahlik to inform fellow employee Mr. Michaud to remove the DVD player from the restricted area for the evening. After receiving instruction from the MFM, Mr. Cahlik inquired to Mr. Dana the location of Mr, Michaud. Mf. Dana informed Mr. Cablik that Mr. Michaud was dealing with the clean up of broken glass in the west side parking lot. Mr. Dana asked Mr. Cablik why he needed Mr. Michaud and Mr, Cahlik relayed the instruction received from the MEM regarding the removal of the DVD player. Upon hearing the instruction relayed to Mr. Cablik from the MFM, Mr. Dana questioned why Mr. Michaud had to perform this work. Mr. Cahlik told him that the MFM wanted it performed by Mr. Michaud because he was trained on the installation of the equipment. According to Mr. Cablik, Mr. Dana stated that " a baby could do this work and it only required the removal of three wires". After this discussion with Mr, Cablik and without the approval of the MEM or any other zoo supervisor Mr. Dana traveled to the tiger exhibit to remove the DVD equipment. Once he arrived at the tiger exhibit, Mr. Dana did not call Ms, Nill or any other animal department employee responsible for the tigers, did not inquire with any staff or check for himself to see if the tiger was still on exhibit, and since he did not have a key to the barrier fence gate he jumped over the barrier fence in order to access the DVD player. During his removal of the equipment Mr. Dana came too close to the exhibit fence with his back and the tiger on exhibit jumped on the mesh and was able to scratch Mr. Dana's back resulting in moderate injury. After the injury, Mr. Dana who has had workplace injuries during his employment at the zoo and is aware of the zoo's policy requiring the notification of injury to zoo management and the completion of a work place injury form, did not inform any management or other staff members of his injury and did not complete the required paperwork, Later that evening without the notification to the zoo of the injury, Mr. Dana sought treatment for his injuries at a local hospital, When later question by the AZD about whether Mr. Dana had informed the hospital of the nature of his injury, Mr. Dana stated that "I just told them it was an animal injury and refused to fill out a requested incident report at the hospital." When asked by the AZD, Mr. Dana stated that he did not inform the hospital that he was involved in a workplace injury or that the injury occurred at the zoo. Due to the extent of the bruising and contusions on Mr. Dana's back, the hospital instructed Mr. Dana to refrain from work the following day, Mr. Dana texted in sick to the MFM on the morning of Wednesday May 18, 2011, but did not divulge the nature or cause of his injury. The MFM then proceeded to call Mr. Dana and discuss the nature of his illness and whether he needed to be seen by a doctor and Mr. Dana said "he was sick, had gone to the hospital and received antibiotics, and it was not a big deal”, FWCDLE 208 (09/08) Page 2 of 4 4 4 Upon returning to work on Thursday May 19, 2011, Mr, Dana approached the MFM and fellow worker Mr. Paul Bedard. During a brief discussion where the MFM questioned how he was feeling and inquired further about his illness, Mr. Dana stated that he did not want to tell the MFM and really needed to talk to "Keith" the zoo's AZD. The MFM questioned whether he had fallen off a ladder or some type of related injury and Mr. Dana divulged to Mr, Bedard and the MFM that he was "hit from behind by the tiget”. Upon hearing this information, the MFM. instructed Mr. Dana to proceed to the 200 hospital to discuss the incident with the AZD and the MFM immediately contacted the AZD by text to inform him of Mr. Dana's pending arrival, Soon after arriving at the hospital, the AZD had a series of meeting with involved staff to discuss the details of the incident, These staff members included Mr. Dana, Mr. Michaud, Mr. Eric Cassidy, and Ms. Naney Nill. Additionally, Mr, Cahlik was reached by phone to confinn the details of the incident. During the series of meetings, Mr. Dana confirmed that he entered the restricted tiger area without permission, that he knew he was required to call the lead keeper prior to entering the area, that he was aware that he did not have a key to the restricted area because he was not permitted entry to this area without permission, and that Ms. Nill did inform him previously in the day that he was never to bop the tiger fence without permission. Additionally Mr. Dana acknowledged that he was aware of the zoo policy regarding reporting workplace injuries and that he purposefully violated these policies to avoid "getting in trouble” FWDLE 208 (09/08) Pagesota Y) | have read this statement and initialed all corrections. | fully understand its entire contents and solemnly ewear (or affirm) that itis true and correct. ‘Signature of Person Giving Statement SUBSCRIBED and sworn to (or affirmed) before me, a law enforcement officer authorized to 7 ~ Signature of Officer administer oaths pursuant to Florida Statute 417.10. ee Name of Officer (Print) FWCDLE 208 (09/08) Page 4 of 4 4 7 39-10 BMIOYRIS OR MEME] ‘ACCIDENTS, INJURIES 7 ‘Detecasin if the accident o injury requses emergency medical assianos if 0, eal Zoo Base, 24 ploy iy ones das aot equ entgenn teatment, onc the explosee's supervisor mi he eis to have ao Bplayee Aviso! Report completed, then rept te Anjos othe Cota’ works compensatieninaraos cari. Inthe event tate vic’ inf o likes doe not ei emecgncytetnent report he lncident oti Shop or deartmoct oud and cca chavo Vitor Achient Report compet ther fc th nj report tha Conny ore asin cacen. All sales ies mat be oposted. Tun al repre into Pectonel. No riot ito Bligh or vit oor. 2 FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION DIVISION OF LAW ENFORCEMENT ACCIDENT INFORMATION FORM (For Fatal or Severe Injury Accident) Please Fax To Appropriate Section within 24 Hours (7 Boatwn acciDent (850) 488 ~ 9264 Incidenti Summary #; FWSA-16-OF F-3495 Date of Incident: 4/45/2016 County: Palm Beach’ CJ HUNTING ACCIDENT (650) 921 ~6453 (C7 ALLIGATOR INCIDENT (650) 921 ~ 6263 a Agency: FC Day of Wook: Friday Timo of Day (mil; 1355 Nearest City or Town: West Palm Beach Location of the Incident: 1201 Summit Or State Waters Ti att shore No. of Vesseljs) Involved: NA No, of Injured: Zero No.of Fatalities: Ore No, of Missing; Zer0 : Vessel Descripton(s): Vessel# 1: Regi NA Length: NA Woke: NA typeof Vessel, NA a Tee Ton Tier Vessel# 2: Regi NA Length: NA. Make: NA Type of Vessel, NA TF Ree I com Pico ‘Subject Information: (Use additional sheets if necessary) VESSEL #1: Name ‘DOB City/State of Residence Fatal Missing Injured ~—_Uninjured esr NANA ee Occupant t: Hai Gc oR oP Occupant 2: a ai - ‘Occupant 3: a Co rr VESSEL #2: amo DOB — City/State of Resklence Fatal Missing Injured —Uninjured ee NA NA (eieee lea G mr Occupant [ i rc Occupant 2: aaea| Gee ‘Occupant 3: G a ies Notified Fatality investigator Byes = No ‘Arrival Tine (ri) Investigator: Erk Howell Suponisor: Lt Jon Garzantt Phone Number: (XB) XX XXX fees = [J NO Name: Alcita Kinman Other Oficers on Scene: yes no Namo: Capt Jones, Lt Garzanit, West Paim Beach Of Otar Agoncls onthe Soone: — K YES [| NO Name: West Palm Beach Police Depariment Alcohol Related: Dives [No JR] UNKNOWN Arrest I No 7 PENDING Nan State Attorney Notified: [7 yes XINO Nextof kin Notified: [XI YES [~ NO 7 Accident Description: __(Briefly descrive what happened) (On 41872018, a Palm Boach Zoo enpleyoo ontored the right House aea fhe tiger erdosure, At enproximately by alter nat had access tthe me. The velim wae darted Stacey F. Kerwsor, DOB of 81911978, 1956, the employee was flay atackod Fwcote osm)

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