Surrender Questionnaire (Dog) The purpose of the questionnaire is to evaluate the dog's needs and determine the most appropriate foster home for the 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. Your Details Name* First Last Address* Street Address City State Postcode Municipality/Council* Email* Phone Number* Alternate ContactAlternate contact person* First Last Alternate contact phone*Alternate contact Email* Details of Animal for SurrenderName* Breed* Colour* Date of Birth (or approximate age)* Sex* Male (desexed) Female (desexed) Male (not desexed) Female (not desexed) Current weight (approximately)* Is your pet microchipped?*YesNoNot SureMicrochip Number* Household Information Please list everyone living in the home (including yourself). Example: Mary, 30 years old, Female Name, Sex, Age* Household Pets Please list in other pets (dogs or cats only), not including the one being surrendered. For example: Fluffy, cat, female, 10 years Name, Sex, Age If you have any other pets (for example: rabbits, guinea pigs, livestock, horses) please just list the species and number of animals below. Eg. 2 guinea pigs and 1 rabbit. Reason for surrendering Please be as detailed as possible. Primary reason for surrender*Behaviour challengesBite incidentFinancial hardshipChange of circumstances - MovingChange of circumstances - IllnessOtherPlease provide more information regarding your reason for surrender* HistoryWhere did you get the dog? (Breeder, pet shop, friend/family, animal shelter, pound, rescue group, Gumtree etc.)* How old was the dog when you acquired him/her?* How long have you had the dog?* What steps have you taken to address the issues relating to the need for surrendering the dog?* HealthPlease provide the name of the vet clinic(s) the dog has been to since you have owned him/her* Has the dog had any illness, disease or injury, past or present?*YesNoPlease provide as much detail as possible relating to this Has the dog had any procedures or surgeries, past or present? (including desexing)*YesNoPlease provide as much detail as possible relating to this* Has the dog had a vaccination within the last 12 months?* Yes No Not sure How old was the dog when desexed? (if applicable) What do you feed the dog? Please be specific (type of food, brand, amount)* Living ArrangementsWhere 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 is the dog left alone per day?* Exercise and EnrichmentOn average, how often do you exercise the dog per day?* Twice per day or more Once per day A couple of times a week Once a week Rarely Never On average, how long are these exercise sessions?* More than 1 hour 45 - 60 minutes 30 - 45 minutes 15 - 30 minutes Less than 15 minutes Not applicable On average, what is the intensity of each exercise session?* Run Jog Brisk walk Slow walk Enrichment walk (dog is allowed to sniff and go at own pace) Not applicable How do you walk the dog?* Flat collar Front attaching harness Back attaching harness Halti Slip lead Martingale collar Choker chain collar Prong collar Off lead Not Applicable Behaviour around other animals and peopleHow does the dog behave around other dogs? Please detail.*How does the dog behave around cats? Please detail.*How does the dog behave around young children? Please detail.* BehaviourPlease tell us about the dog's personality and behaviour traits*What are the dog's likes?*What are the dog's dislikes?*What are the dog's fears/phobias?*What are the dog's bad habits?* Training What, if any, obedience/training/behaviour sessions has the dog had? Please detail when, where and what it involved*What can your dog do when requested?* Select All Look Sit Down Stay Comes when called Touch Shake Wait Give Leave Go to bed/mat Nothing Other Please provide more information:If allowed inside, is the dog fully housetrained? (No accidents inside for at least 3 months)* Yes No Not applicable What training techniques have you tried?* Select All Rewards - 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 Please provide further information: AggressionWho are the targets of your dog's aggression?*How often does the dog growl or snarl at people?* Never Rarely Sometimes Often Frequently How often does the dog growl or snarl at other dogs?* Never Rarely Sometimes Often Frequently How often does the dog snap at people?* Never Rarely Sometimes Often Frequently How often does the dog snap at other dogs?* Never Rarely Sometimes Often Frequently How often does the dog bite people?* Never Rarely Sometimes Often Frequently How often does the dog bite other dogs?* Never Rarely Sometimes Often Frequently Has the dog ever held on and shaken or given multiple bites to a person?* Yes No Has the dog ever held on and shaken or given multiple bites to another dog?* Yes No Has the dog ever held on and shaken or given multiple bites to another animal?* Yes No Has the dog ever caused serious, major or life threatening injuries to a person?* Yes No Has the dog ever caused serious, major or life threatening injuries to another dog?* Yes No Has the dog ever caused serious, major or life threatening injuries to another animal?* Yes No Has the dog ever killed a person or animal?* Yes No Have you or the dog been reported or had legal action taken against them, relating to the dog?* Yes No Final QuestionsHow long can you hold onto the dog for until we find a suitable foster home?* Less than one week 1 - 2 weeks 2 - 4 weeks 4 - 8 weeks 8 - 12 weeks As long as needed, I just want the perfect home! If you cannot hold onto the dog are you able to contribute towards the cost of boarding the dog in kennels at a rate of $40 per day until we can find a suitable foster home?* Yes No 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 vet check and vaccination $250 - Covers first two weeks in foster $500 - Covers first month in foster $1500 - The average cost for us to rehome one dog 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 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. Signature*NameThis field is for validation purposes and should be left unchanged.
