Adopter’s Home Visit Report Web Site Interviewer Information Your Name * Your Email * Adopter Information Date of Home Visit Potential Adopter's Home Phone * Name(s) of Potential Adopter * Street Address * City * State Zip * How were you welcomed? Excited Warm Reserved Indifferent Happy Calm Nonchalant Irritated How was your dog welcomed? Excited Warm Reserved Indifferent Happy Calm Nonchalant N/A - no dog taken Did all family members enjoy your dog? Yes No N/A - no dog taken If no, please explain Did you or your dog dislike any family member? Yes No If yes, please explain Who was present during your visit? (# of adults, # of children, names) If one person is intended to be the primary care provider for the dog, who will that person be? Are they aware that some Chihuahuas and small dogs are diggers and great escape artists? Yes No Environment Information Does the yard have shade? Yes No N/A - no yard Does the yard have a fence? Yes No N/A - no yard If there is a fence: what type, height, condition, and approximate size of the fenced area If there is a fence, does it have any holes, gaps, or weak spots? Yes No If there is a fence, are there locks on the gates against children and thieves? Yes No Is there anything stacked near the fence the dog could climb to get out? Yes No Will they fix any problems with the fence before adopting a dog? Yes No If they need to fix the fence, what do they plan to do to fix it? Are signs of poisonous plants in the yard? Yes No Any signs of a dog house or indications of a dog living outside? Yes No Housing Information Do they live on a busy street? Yes No Please describe the setting Are they aware that every time they open a door, they will need to be careful about their new little one escaping? Yes No How do they plan on preventing any escapes? Do the storm doors close and latch properly? Yes No Do they have areas that are closed off from the dog? Yes No Where will the dog food be stored and will it be properly kept out of reach of the new little one? Where and how is the garbage stored and will it be kept out of reach of the new little one? Have they owned a small breed dog before? If so, what breed(s)? What do they like about the current or past dog(s)? What did they dislike about their current or past dog(s)? What plans do they have for the dog's care for any overnight absences or while on vacation? Where will the dog eat? House Crate Couch Dog House Kennel Kitchen Outside Other If other, please explain: Where will the dog sleep? House Crate Couch Dog House Kennel Owner's Bed Outside Other If other, please explain: Are there house plants (many are poisonous)? Yes No Are there chemicals in the garage, basement, or storage areas that the dog could gain access to? Yes No Are they aware that certain foods and substances (chocolate, onions, grapes, raisins, and antifreeze, to name a few) are toxic to dogs and can cause sickness and/or death? Yes No Children Information Do all the children in the family seem responsible and dog friendly? Yes No N/A - no children If no, please explain: Did parents intervene appropriately, if necessary, and monitor the interaction of the children and pets? Yes No N/A - no children Did you discuss the importance of having adults supervise play between children and pets to keep both children and dogs safe and did parents acknowledge this need? Yes No N/A - no children Are they aware that toys must be kept out of reach of dogs as they will likely be chewed and possibly swallowed by a dog? Yes No N/A - no children Other Pet Information Are there currently other pets in the family? Yes No If yes, please describe: How did the family pets (cats, dogs, etc.) respond to you? Friendly Inquisitive Excited Annoyed Barked Indifferent Mean Ran and hid Wary Other N/A - no other pets If other, please explain: How did the family pets respond to your dog? (if applicable) Friendly Annoyed Barked Indifferent Played, but unacceptably rough or dominant Mean Ran and hid Wary Played nicely Other N/A - no other pets If other, please explain: How did they react with the current pets? Attentive Indifferent N/A - no other pets Are the current pets well socialized? Yes No N/A - no other pets How did the pets respond to commands given by the family members? Complied Ignored N/A - no other pets Are the current pets reasonably clean? Yes No N/A - no other pets Are the current pets friendly? Yes No N/A - no other pets What activities do they intend on doing with their possible new family member? Would you feel comfortable having this applicant take care of your dog if you went away on vacation? Please explain. * General impression of this applicant and their ability to provide a safe and caring home for one of our little ones. Verification Please enter any two digits * Please click the submit button only one time. When you see the thank you message, your form was submitted.
