Midwest Shiba Inu Rescue

Online Home Visit Report Form

Applicant Information:

Applicant(s) Name:     (required)

Applicant's Email address:   (required)

Applicant(s) State:   

Date of Visit: 

Dog being considered:    

Identify all family members and ages:

Who will be the main caretaker; and are they physically capable of taking care of the dog?

 

 
Applicant's Home

Do they live in a : House ApartmentCondo Trailer Other

If "Other" please explain:

Condition of Home:

Are the quarters dog-friendly?
Will they allow dog to have free run of the house when they are home?

Are there "child gates" available to block off portions of the house?:

Where will the dog sleep?

Where will dog stay when left alone?

If dog will be crated, how long will dog be crated? (daily or weekly) (include crate size, type and location)

Potentially hazardous items?

Outside Doors (describe each):

1. Location of door:

    Potential for escape:          

    Potential for harm:

2. Location of door:

    Potential for escape:

    Potential for harm:

3. Location of door:

    Potential for escape:

    Potential for harm:

Other comments on home:


Applicant's Neighborhood:

Describe the street: Busy Quiet In-Between

Describe the setting: Rural Suburban Urban

How close to a major (busy) road?

Other comments on neighborhood:

Applicant's Outside Exercise Area:
 

Is there a yard?

Condition of yard?

Is yard securely fenced?

Describe Fenced Area (height, type, condition):

If no fence or tie-out area, where will dog be exercised? How will dog be exercised, e.g., walk on leash, run in park? How often will dog be exercised? How will dog relieve itself?:

Applicant's Current Pets:

1. Current pet's name:  Type of Pet:  Sex:  Age:   How long owned:  Where kept: 

2. Current pet's name:  Type of Pet:  Sex:  Age:   How long owned:  Where kept: 

3. Current pet's name:  Type of Pet:  Sex:  Age:   How long owned:  Where kept: 

4. Current pet's name:  Type of Pet:  Sex:  Age:   How long owned:  Where kept: 

Potential issues integrating with pets?: 

  

Family Behaviors:

Describe the behavior of family members among themselves, to children, to any other pet(s), e.g., (respectful, hectic, loud, quiet, commanding).

Describe the behavior of children towards pet, e.g., (calm and cautious, obedient, bouncing off the walls, etc.)

Will the family's lifestyle provide enough quality time for the dog?:    

Family Knowledge Evaluation:

General dog care, including regular vaccinations, heart worming and flea/tick protection?

Shiba Inu attributes, including negatives, e.g., escaping, aloof, dog aggressive, child uncertainty, etc.? 

Grooming, e.g., nails, bathing frequency, coat maintenance, etc.?

Feeding frequency, amounts, food quality, and potential supplements? 

Foods that are a danger, e.g., onions, chocolate, grapes, cooked bones, etc.?

Weight control and the proper weight for the dog that is being considered?

Costs of maintaining a dog, e.g., Vet, food, insurance, boarding, etc.? 

Need and plans for obedience training, especially with all family members?

Recognizing and knowing what to do about common problems, e.g., separation anxiety, aggressive behavior, rehousebreaking, body chewing, allergies, hotspots, etc.?

Summary:
 

Are there any other items, special needs, unusual limitations, or other concerns that should be investigated further?

 How do you feel about the safety, care, love and compassion a dog will receive if adopted to this family?

 


 Additional information/comments:

Home Visit Evaluator Name:  (required)

Date: 

Evaluator email address:  (required)