Dog Surrender Pre-screening Questionnaire (2024)

Name *

First

Last

Phone Number *

Pronouns: *

She/Her/HersHe/Him/HisThey/Them/TheirOther

Preferred method of contact:* *

PhoneEmail

Preferred time of contact:* *

MorningAfternoonOption 3

Have you used JHS services before?* *

YesNo

Dog's name: *

Age and/or Birthday: *

Sex *

Male- NeuteredMale- IntactFemale- SpayedFemale- IntactI don't know

Weight *

Color(s) *

Dog breed *

Distinguishing Markings: *

What is the reason for needing to re-home your dog? *

Have you taken any steps to resolve or remedy the reasons that are causing you to re-home your dog? *

YesNo

Are you willing to temporarily foster your dog until it can be adopted? *

YesNo

If we could provide you with any of the following resources, would you be able to keep your dog? *

Dog HouseOutdoor tie-outCrateFlea PreventionSpay/NeuterMicrochipCollarDog FoodVaccinationsLeashBehavior/ TrainingPet medical assistancePet Rent/ pet deposit assistanceNone of theseOther

Are you interested in private re-homing through our Supported Re-homing Services? *

YesNoUnsure, give me more informatio

Has your dog been vaccinated in the last 12 months? *

Is your dog microchipped? *

Is your dog on any medications or special diet?* *

YesNo

What brand of dog food do you feed your dog? *

How often is your dog fed?* *

Once a dayTwice a dayOther

Does your dog have any allergies or medical conditions? *

YesNoUnknown

Where did you get your dog from? *

Where has your dog been living primarily? *

How long is your dog left alone, without people, on a typical day? *

Is your dog housetrained? *

Does your dog show any of the following signs of anxiety or abnormal behavior when left alone for short periods of time? *

Please explain more about your dog's level of housetraining: *

What toys and games does your dog like? *

BallsFrisbeePlush ToysWrestlingTug GameSqueaky ToysTug ToysFetchChaseUnknownOther

When your dog plays, does he/she typically: *

JumpBarkBite hardGrowlBite lightlyUnknownNone of theseOther

What commands does your dog know? *

SitComeStayDownHeelShakeSpeakUnknownNoneOther

Is your dog afraid of anything? *

Is your dog allowed on the furniture? *

Does your dog escape your property? *

Please tell us your dog's "bad habits". If there aren't any, enter "none".Comment *

Please tell us something interesting, unique or fun about your dog, his/her traits, or personality that we can tell potential adopters: *

Has your dog ever reacted to a FAMILIAR PET by growling, showing teeth, snapping, or biting during any of the following situations: *

Yes, when approached by a familiar pet while in their favorite resting placeYes, when approached by a familiar pet while playing with or chewing a favorite toy, bone, treat, object, ect.Yes, when approached by a familiar pet while being walked/exercised on a leashYes, when approached by a familiar pet while eatingYes, when approached by a familiar pet while engaged in another activityNone of these

Please describe the activities that led up to any snap or bite occurrence with a familiar pet: *

Has your dog ever reacted to an UNFAMILIAR PET by growling, showing teeth, snapping, or biting during any of the following situations: *

Yes, when approached by an unfamiliar pet while in their favorite resting placeYes, when approached by an unfamiliar pet while eatingYes, when approached by an unfamiliar pet while playing with or chewing on a favorite toy, bone, treat, object, etc.Yes, when approached by an unfamiliar pet while engaged i another activityNone of these

Please describe the activities that led up to any snap or bite occurrence with an unfamiliar pet: *

Has your dog ever attacked another animal resulting in severe injury or death? *

Yes, other dogsYes, catsYes, livestockYes, small pets (hamster, guinea pig, etc.)Yes, wildlife (squirrels, etc.)No, my dog has never reached to another animals as described

Please describe the activities that led up to any occurrence of injury or death of another animal by your dog: *

Has your dog ever reacted to other animal types by growling, showing teeth, snapping, or biting? *

Yes, other dogsYes, catsYes, livestockYes, small pets (hamster, guinea pig, etc.)Yes, wildlife (squirrels, etc.)No, my dog has never reacted to other animals as discribed

Please describe the activities that led up to any snap or bite occurrence with another animal: *

What types of people has your dog lived with? *

Infants/toddlesSmall ChildrenTeenagersAdults- MaleAdults- FemaleOther

What ages were the children or teenagers? *

Has your dog ever reacted to a person by growling, showing teeth, snapping, or biting during any of the following situations: *

Yes, when approached by an unfamiliar person of child while in the homeYes, when approached by an unfamiliar person child while eatingYes, when approached by a familiar person or child to take away or remove a favorite toy, bone, treat, object, etc.Yes, when approached by an unfamiliar person or child while being walked/exercised on leashYes, when approached by a familiar or unfamiliar person or child while engaged in another activityNo, my dog has never reached to other people as described aboveOther

Please describe the activities that led up to any snap or bite occurrence with a person or child: *

Has your dog ever inflicted a bite to a person that broke the skin? *

YesNoUnknown

Has your dog ever shown any of the following behaviors when being bathed or brushed, having their paws wiped, or having their harness or collar put on? *

FearShows teeth/ growlsSnapsBitesNone of theseUnknown

I am the owner or authorized agent/designee for the owner of the animal described above. *

I agree

The information provided in this questionnaire is accurate and true to the best of my knowledge. *

I agree

I understand that by submitting this questionnaire, it does not guarantee an appointment to surrender my animal(s) to Joplin Humane Society. *

I agree

I acknowledge that by completing this questionnaire I am requesting pet surrender support and/or services through Joplin Humane Society and that I will be contacted at a later date to discuss my pet(s) and schedule an intake appointment, if necessary. *

I agree

Signature *

Date *