First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Country

Email*

Home Phone*

Work Phone
x

Cell Phone*

Alt Email

Name of TSBR Volunteer Conducting Home Visit*

Date you conducted the Home Visit

Is the residence situated on or near a busy road?*
Choose one: Yes No

What type of home is the residence?
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Are the living quarters animal friendly?
Choose one: Yes No

Is there a lot of clutter, or is the house to neat? If yes, please explain below.
Choose one: Yes No

If you answered yes above, please explain here:

Are there lots of small objects, kids toys, cat toys, exposed cords, cleaning supplies, houseplants, etc., that the dog may be able to access?
Choose one: Yes No

If yes, please explain here:

If the home is a rental, has the landlord approved having a large breed dog (50+ pounds)?*
Choose one: Yes No Not Applicable

Is there a garage?
Choose one: Yes No

Would you have any concerns about the dog having access to the garage?
Choose one: Yes No Not Applicable

If you have concerns about the dog having access or any other concerns about the garage, please explain below:

Is there a yard?
Choose one: Yes No

What is the size of the yard?
Choose one: Very Small Small Medium Large Extra Large Not Applicable

Is the yard fenced?
Choose one: Yes No

Is the fence totally enclosed?
Choose one: Yes No

Does the fence touch the ground in all areas?
Choose one: Yes No

Is there direct access from the house to the fenced area?
Choose one: Yes No

What type of fence is in place?
Choose one: Wood Chain Link Wrought Iron Invisible Fencing Combination of types Not Applicale (No Yard)

What is the approximate height of the fence?
Choose one: Less than 4 Feet 4 Foot 5 Foot 6 Foot 8 Foot Greater than 8 Foot

Is the fence in good repair?
Choose one: Yes No Not Applicable

Do you have any concerns about a dogs safety in this yard (any gaps a dog could escape, places they could be injured, material stacked, debris the dog could get into, etc.)?
Choose one: Yes No Not Applicable

If you answered YES, please explain below:

Are all gates padlocked? If not, is the applicant willing to lock or otherwise secure the gates?
Choose one: Yes No Not Applicable

Is thre a pool?
Choose one: Yes No Not Applicable

If there is a pool, is it fenced/secured?
Choose one: Yes No Not Applicable

If there is no fenced or otherwise completely secured area, how will the family ensure the dog has adequate opportunity to relieve itself, and is exercised? What is their willingness to walk the dog in the elements (cold, hot, rain, wind)?

Is there a dog house in the yard or on the property?*
Choose one: Yes No

Is there an outside kennel or dog run in the yard or on the property?*
Choose one: Yes No

If there is a dog house, outside kennel/run on the property, please explain in detail your discussion with the applicant about these items (otherwise use N/A).*

Please add any additional comments/concerns over the fence and/or yard (description of fence, any concerns, does it appear the dog lives outside, etc.).

Where and how would the dog be kept when the family is not at home? Note specific room/area of house. Please list one: crate, baby gate, run of house, other?

How long would the dog be left home alone unattended on a daily Basis?*

How many hours each day would they have to spend with the new dog? (Is it sufficient given the age/activity level of dog they want?)

Where and how will the dog be exercised? (Daily Walks, Exercised in fenced yard, etc)

It may take several weeks for the new dog to adjust to the new home. Is the family willing and prepared to allow for this transition time?
Choose one: Yes No Undecided

Please explain any concerns or observations below:

When would the dog be outside?

Does the family have any experience with crating?
Choose one: Yes No

How does the applicant feel about crating and do you have any concerns about this?

Does the applicant understand the requirement for the dog to be leash walked and supervised when outdoors?
Choose one: Yes No Undecided

Please note any concerns you might have over the dog being walked on a leash.

Did the applicant mention desire for having the dog off-leash?
Choose one: Yes No

Did you get the impression that the potential adopter will exercise the dog on a regular basis (regular meaning daily)?
Choose one: Yes No

Please explain any concerns you might have over the dog getting regular exercise:

Engage the applicants in conversations about the dog they want to adopt and about themselves. Observe behavior. Try to get a sense of what type of pet owner they are or will be. Did you meet all family members who reside in the home?
Choose one: Yes No

Who will be the primary caregiver?

Does one member of the family clearly want the dog more than others?
Choose one: Yes No Undecided

Did you get the impression that anyone in the family is opposed to the adoption?
Choose one: Yes No Undecided

If yes, please explain below:

Describe the behavior of adults among themselves, other pets, or children ((e.g. respectful, hectic, loud, quiet, commanding, etc.)

Describe the behavior of children in relation to adults, to other children and to any pets.

Will the parents supervise the childrens interaction with the dog?
Choose one: Yes No Not Applicable

What research has the family done about the breed? What do they know about the breed?

What type of personality/temperament do you think would best fit in the family's household and with their lifestyle?

Do the applicants have a realistic understanding of a sporting dog's needs and behaviors?
Choose one: Yes No Undecided

Does the family have large dog experience?
Choose one: Yes No Undecided

Have they owned a large rescued dog before?
Choose one: Yes No

Are there other pets in the home?
Choose one: Yes No

Do these pets appear well cared for and happy?
Choose one: Yes No Undecided

Do they exhibit any negative behaviors?
Choose one: Yes No Undecided

If yes, please explain below:

Are the other dogs/pets overweight and do you have any concerns regarding their general health or appearance?
Choose one: Yes No Undecided

If yes, please explain below:

How will they introduce the new dog to the current pets?

Are there any special needs, unusual circumstances or concerns that we should be aware of?
Choose one: Yes No Undecided

If yes, please explain below

What characteristics (age, color, sex, personality) are they looking for in their next dog? How firm are these characteristics?

List any TSBR dogs they specifically mentioned:

What sporting breed(s) are you considering for your family? Note: Some breeds are more commonly found in our local shelters or surrendered to a rescue organization.

Would you feel comfortable leaving your dog with the applicant?
Choose one: Yes No Undecided

If NO or UNDECIDED, please explain your reservations below.

Other comments, observations or recommendations: