Surrender Questionnaire (Dog) "*" indicates required fields Step 1 of 14 7% The purpose of the questionnaire is to evaluate the dog's needs and determine if we have the capacity, capabilities and resources to adequately assist this dog. No one knows your dog the way you do, so we implore you to take the time to fill out this questionnaire with care, accuracy and as much information as possible to give the dog the best possible chance of success. Estimated time to complete: 60-75 minutes We recommend completing this form on a desktop Your DetailsName* First Last Date of Birth DD slash MM slash YYYY Address* Street Address City State Postcode Email* Phone Number* Secondary ContactAlternate contact person* First Last Email* Phone* Animal DetailsName* Date of Birth* Breed* Colour(s)* Sex* Male Female Desexed?* Yes No Current weight (kg)* Microchip Number* Reason for SurrenderPrimary reason for surrender*Behaviour challengesBite incidentFinancial hardshipChange of circumstances - MovingChange of circumstances - IllnessOtherPlease provide more information regarding your reason for surrender* HistoryWhen did you get the dog?MonthYear Add RemoveWhere did you get the dog?* Breeder Pound/shelter Rescue organisation Home2Home Friend/family Facebook Gumtree/trading post Pet shop Other Name of rescue group* Have you spoken with the rescue organisation regarding the challenges and your decision to rehome?* Yes No Other Name of pound/shelter* Have you spoken with the pound/shelter regarding the challenges and your decision to rehome?* Yes No Other Name of breeder* Have you spoken with the breeder regarding the challenges and your decision to rehome?* Yes No Other Please provide more information regarding this communication*What steps have you taken to address the issues relating to the need for surrendering the dog?* Living ArrangementsResidents currently living at the house*Including youNameSexAge Add RemoveAre there any other pets living at the home?* Yes No Other pets*NameBreedAgeSex Add RemoveWhere does the dog currently sleep at night?* Where does the dog have access to when no-one is home?* Where does the dog have access to when someone is home?* On average, how many hours per day is the animal left alone?* < 1 hour 1 - 2 hours 2 - 4 hours 4 - 6 hours 6 - 8 hours > 8 hours What is the longest length of time you have left the animal alone for?* < 1 hour 1 - 2 hours 2 - 4 hours 4 - 6 hours 6 - 8 hours > 8 hours HealthName of vet clinic(s) dog has been to* Has the dog had any veterinary procedures or surgeries?* Yes No Please provide more information*Has the dog had any physical illness, disease or injury?* Yes No Please provide more information*Is the dog currently on any medication?* Yes No What medication?*DrugDoseFrequency Add RemoveWhat is the dog's main diet?*BrandType Add Remove TrainingHave you ever had a behaviour trainer assess and assist you with the dog? Yes No Name of training company/trainer* What training techniques have you tried?* Positive reinforcement - treats, pats, attention Clicker Ignoring Time out Loud/stern voice Citronella collar Shock or electric collar Clapping hands Tap across nose Spraying water Alpha roll or pinning down Force None Other What equipment do you currently use to walk the dog?* Flat collar Back attaching harness Front attaching harness Halti (over the nose) Slip lead Martingale collar Choke chain collar Prong/pinch collar None Behaviour - GeneralDescribe the dog's personality and behaviour traits*What are the dog's likes?*What are the dog's dislikes?*What are the dog's triggers/fears?*What are the dog's challenging behaviours?*Which of the following behaviours have you witnessed the dog performing?* Biting Chasing lights/shadows Chasing their tail Chewing items Destructive behaviour Digging in the garden Digging under fences Excessively barking Excessively howling Excessively chewing themselves Excessively licking themselves Excessively scratching themselves Excessively staring at seemingly nothing Growling Hyper fixating Humping Inappropriate defecation (ie. inside) Inappropriate urination (ie. inside) Jumping on people Jumping on tables/benches Jumping over fences Lunging towards other dogs Lunging towards people Pacing Pulling on lead Neediness Nipping Mouthing Resource guarding food Resource guarding items Resource guarding people Restlessness Scavenging food Snapping Snarling Trembling (when not cold) Whining Yawning (when not tired) Behaviours - SpecificIn this section we want you to do your best to describe behaviours you have seen your dog perform in specific scenarios. Think about what the dog did and body language they displayed. Try to use descriptive words. Please describe the behaviours you have seen them perform around unfamiliar people*Please describe the behaviours you have seen them perform around other dogs*Has your dog ever seen or interacted with a cat?* Yes No Please describe the behaviours you saw your dog display in this situation*Has your dog ever seen or interacted with a child?* Yes No Please describe the behaviours you saw your dog display in this situation*Please describe the behaviours you see your dog performing when you are preparing to leave them alone at home* Behaviour - AggressionThis includes behaviours such as growling, bearing teeth, snapping, lunging, bitingHow often has the dog shown aggression towards adults? This includes growling, baring teeth, snarling, snapping, lunging or biting?* Never Rarely Sometimes - At least once per week Frequently - At least once per day How often has the dog shown aggression towards children? This includes growling, baring teeth, snarling, snapping, lunging or biting?* Never Rarely Sometimes Frequently How often has the dog shown aggression towards other dogs? This includes growling, baring teeth, snarling, snapping, lunging or biting?* Never Rarely Sometimes Frequently How often has the dog shown aggression towards other animals? This includes growling, baring teeth, snarling, snapping, lunging or biting?* Never Rarely Sometimes Frequently Has the dog ever held on and shaken or given multiple bites to a person, child or baby?* Yes No Please provide more information*Has the dog ever held on and shaken or given multiple bites to another dog?* Yes No Please provide more information*Has the dog ever held on and shaken or given multiple bites to another animal?* Yes No Please provide more information*Has the dog ever caused serious, major or life threatening injuries to a person, child or baby?* Yes No Please provide more information*Has the dog ever caused serious, major or life threatening injuries to another dog?* Yes No Please provide more information*Has the dog ever caused serious, major or life threatening injuries to another animal?* Yes No Please provide more information*Has the dog ever killed a person, child, baby or animal?* Yes No Please provide more information* RehomingHow long can you continue to care for the dog?*Behaviour applications are assessed and processed in order of receipt. This question is to help us determine if we will have enough time to be able to adequately assist. Less than two weeks 2 - 4 weeks 1 - 3 months As long as needed, I just want the perfect home! Other If we can accept the dog into our foster program how much are you able to contribute to the foster care and rehoming costs? (Donations are tax deductible)* $100 - Covers a behaviour assessment $250 - Covers a behaviour assessment & health check $500 - Average cost of one month in foster $1000 - Average cost of three months in foster $2000 - Average cost for us to rehome one dog Other Please attach photos of the dog*If you have any issues uploading images, please email them through to hello@projectunderdogrescue.org.au Drop files here or Select files Max. file size: 50 MB, Max. files: 3. How did you hear about Project Underdog Rescue?* Google Facebook Instagram Pet Rescue Adopt-A-Dog Referral Other Who were you referred by?* I understand that this questionnaire is not a guarantee or promise that Project Underdog Rescue will be able to accept the above mentioned animal into their care.*I understand that this questionnaire is not a guarantee or promise that Project Underdog Rescue will be able to accept the above mentioned animal into their care. I consent to Project Underdog Rescue using the attached images for public advertisement or any other way they deem appropriate.*I consent to Project Underdog Rescue using the attached images for public advertisement or any other way they deem appropriate. I consent to Project Underdog Rescue contacting any veterinary clinics the above mentioned animal has attended to obtain the animal's medical records for the purpose of assessing the animal for placement in their care.*I consent to Project Underdog Rescue contacting any veterinary clinics the above mentioned animal has attended to obtain the animal's medical records for the purpose of assessing the animal for placement in their care. PhoneThis field is for validation purposes and should be left unchanged.
