Clone of Homevisit Form-NEW

Homevisit Form-NEW
Date of Homevisit:

Month Day Year
Potential Adopter Information:
Full Name: *

First Name Last Name
Street Address: *
City: *
State: *
Zipcode: *
Phone Number: *

Area Code Phone Number
Cellphone Number: *

Area Code Phone Number
Animal Applied for: *
Neighborhood:
Describe the street

Busy Quiet In between
Describe the setting

Rural Urban Suburban
Are there loose cats or dogs in the neighborhood?

yes no
What potential hazards are there in the community?
Is there a busy street nearby that would endanger the pet if it got loose?

yes no
Fence/Yard:
Is the yard fenced? *

no yes
if yes, describe how big the area is and the fencing materials:
Is there anything near the fence that the animal could climb on to get over the fence?

No yes
Does the fence appear to need repair?

yes no
Are there potential escape routes ? (i.e. low places near or under fence, holes etc.)

yes no
Are there places in the yard the pet could jump off of and get injured? (i.e. decks, etc.)

yes no
Is there an inground pool?

no yes
Are there plants or chemicals visible in the yard that could be poisonous?

no yes
If no fence, is applicant planning on installing fencing?

yes- invisible/underground fencing yes- physical fence no only if needed
If considering invisible fencing, is the applicant aware that this does not work with all dogs?

yes no
If applicant is installing a fence, when are they having it installed?
When/if you pointed out problems with yard or fence, how did the applicant react?
Do you believe the applicant will correct any issues? *

yes no
Home and Living Arrangements:
Overall condition of the interior of the home: *

clean neat dirty cluttered
Condition of the basement:

clean neat dirty cluttered N/A-none
Condition of the garage:

clean neat dirty cluttered N/A- none
Where will the animal stay when company comes over? *

left loose crated in another room outside other, explain below
Other (please explain):
Where will the animal sleep at night? *
Where will the animal stay during the day? *
Are they prepared to crate the animal if needed?

yes no
Is there evidence of small children?

toys blankets, clothing etc. no
If there are small children, please remind the applicant they will need to watch toys, etc. lying around, since many dogs will chew things up & toys could be a choking hazard
Are there sewing kits, bobby pins, washcloths, sponges, trash cans, razors, at pet level or on counter pets could reach? (if so, point these out)

yes no
Is there access to chemicals? Cleaners, toilet cleaners, inside or antifreeze, etc. in the garage?

no yes
Do the furnishings of the house appear to be pet-proof? (no glass objects, dried flowers, potted plants at pet level, etc)

yes no
Are the living quarters pet-friendly, in your opinion?

yes no need few changes
Interaction with Current Pets:

(if applicable)
Are current pets well socialized? If no, please explain:
Are any current pets reasonably clean?

yes no
Are any of them hand-shy?

No yes
Do they allow you to touch: (check all that apply)

ears tail feet
Do they approach you in a friendly manner?

Yes No
How did they react to a stranger in the house? How did they greet you?
Did they eventually relax and accept your presence?

yes no
How do they respond to the owners, to commands?
If the animal misbehaved, did applicant address it or ignore it?

addressed it ignored it
What kind of discipline, if any, did you observe?

yelling hitting calm correction
If you brought a "homevisit dog" with you, did their pets seem accepting of a new animal in the house?

yes no n/a
Are the applicants aware that some animals need time to adjust to a new family member?

yes no
Family:
Were all family members present?

yes no part of the time
Do all family members seem accepting of a new pet?

yes no
Are there children in the household?

No Yes, (see below)
If yes, please list their ages:
If applicable, how do children behave with pets?

kind gentle heavy handed mean
Is anyone allergic to animals?

no yes
Training/Behavior:
How do they plan to exercise the pet?

walks tie out fenced yard
Will the animal ever be left outside unsupervised?

No Yes Not unless they are home yes when they are home & gone sometimes
How do they plan to discipline for chewing, potty accidents, etc.?
Conclusions:
Do you feel the applicant will love and care for pet properly? *

Yes No
Do you feel the environment is safe for a rescued animal?? *

Yes No yes with changes, see below
Please list any changes needed:
If this were your animal, would you adopt him/her to this family? *

Yes No
Does this adoption feel right to you? *

Yes No I have reservations, see below
Please list any and all reservations you have:
Additional comments:
Volunteer's Name: *

First Name Last Name
Volunteer's Phone Number:

Area Code Phone Number
Volunteer's E-mail Address: *
Should be Empty:

Homevisit Form-NEW

Potential Adopter Information:

Neighborhood:

Fence/Yard:

Home and Living Arrangements:

If there are small children, please remind the applicant they will need to watch toys, etc. lying around, since many dogs will chew things up & toys could be a choking hazard

Interaction with Current Pets:

Family:

Training/Behavior:

Conclusions: