Copy and paste this info into an email to smaguire@calhouncountyiowa.com

This questionnaire has been designed to help us determine whether an adoption is in the best interests of both pet and adopter. Please answer all questions or put NA if they do not apply to you.

QUESTIONNAIRE FOR DOG ADOPTION

SECTION I

Date ________________

NAME______________________________________PHONE H)____________(W)____________

ADDRESS____________________   CITY________________ STATE_______ZIP _________

NAME OF PET Y0U ARE APPLYING FOR _______________________  IF THIS DOG IS IN THE NCCF TRAINING PROGRAM, ARE YOU A FAMILY MEMBER OR RELATIVE/FRIEND OF AN INMATE? ______________ NAME ______________________

EMAIL _________________________________________

ARE YOU:  EMPLOYED________  STUDENT______  RETIRED______  OTHER_______

TYPE OF RESIDENCE:   HOUSE_______  APARTMENT_______  MOBILE HOME______ FARM _____

DO YOU OWN _______  RENT_______ HOW LONG HAVE YOU BEEN AT THE RESIDENCE? _______

                IF YOU RENT, DOES LANDLORD ALLOW PETS?  YES_____   NO_____

                LANDLORD'S NAME________________________________________PHONE____________

                                                                          (WILL BE VERIFIED BY REPRESENTATIVE)

DO YOU PLAN T0 MOVE IN THE NEAR FUTURE?    YES_____   NO_____

ARE OTHER FAMILY MEMBERS AWARE YOU PLAN TO ADOPT A PET?  YES____  NO____

SECTION II

1.     REASON FOR ADOPTION:  COMPANIONSHIP ____   HUNTING _____   4-H ____ 

                                                                        WATCH/GUARD ______ GIFT ____  PET COMPANION ____

                                                                        (IF GIFT, GIVE NAME OF AND RELATIONSHIP TO RECIPIENT)

2.     NUMBER OF ADULTS IN HOUSEHOLD _____   NUMBER OF CHILDREN AT HOME ______

        AGES OF CHILDREN ________________

3.     DO YOU HAVE PETS NOW?  YES ___NO ___  HOW MANY--DOGS___ CATS___ OTHER___

        WHAT BREED, SIZE, AND AGE ARE OTHER DOGS IN THE HOME?

4.     IF YOU HAVE PETS, HOW MANY ARE SPAYED OR NEUTERED? __________

        CURRENT ON SHOTS?  _________

5.  DO YOU HAVE A FENCED IN YARD? _________________ WHAT TYPE OF FENCING AND SIZE OF ENCLOSURE?

6.     WHAT KINDS OF PETS HAVE YOU HAD IN THE PAST?

7.     WHAT HAPPENED TO YOUR LAST PET?_____________________________________________

8.     HAVE YOU EVER LOST A PET DUE TO:  POISONED_____  HIT BY CAR____  DISEASE_____

                                                                                                        STRAYED/STOLEN_____  OLD AGE______

9.     HAVE YOU EVER HAD TO GIVE UP A PET?  YES____  NO____  IF YES, WHY?____________

10.   IF YOU MOVE IN THE FUTURE, WILL YOU BE ABLE TO KEEP YOUR PET(S)? 

                                                                                                                                                YES_____    NO_____

11. ARE YOU AWARE OF AND PREPARED TO MEET THE FIRST YEAR'S COST OF REGULAR PREVENTIVE VETERINARY CARE ($100 TO $200 PER YEAR) AND QUALITY FOOD, SUPPLIES, TRAINING YES _____  NO _____

12.IS ANYONE IN YOUR FAMILY ALLERGIC TO ANIMALS?  YES _____  NO _____

13. WHO IS YOUR PRESENT VET, WHAT IS THEIR CLINICS PHONE NUBMER?      

14. WHAT TIMES WOULD BE BEST FOR REPRESENTATIVE TO CALL OR VISIT?

15. HAVE YOU EVER BEEN REFUSED BY AN HUMANE ORGANIZATION WHEN APPLING TO ADOPT AN ANIMAL?

YES _____  NO _____ , IF YES, WHEN ____________.  WHICH ORGANIZATION? _______________ AND WHAT WAS THEIR REASON FOR DOING SO ________________________________ .

SECTION III

1.     WILL YOUR PET LIVE INDOORS ___________   OUTSIDE ___________

                    WHEN OUTSIDE, HOW WILL IT BE CONFINED?______________________________________

                    WHAT KIND OF SHELTER DO YOU HAVE?_____________________________________

                    HOW DO YOU PLAN TO HOUSETRAIN?________________________________________

2.        DO YOU FEEL WILLING AND ABLE TO WORK WITH YOUR PET AND CORRECT PROBLEM BEHAVIOR IF IT SHOULD DEVELOP (BARKING, FENCE JUMPING, DIGGING, CHEWING, ETC.)? 

                YES _______   NO _______

        WHAT ARE YOUR IDEAS FOR DEALING WITH SUCH BEHAVIOR? (NOT ALL PROBLEM BEHAVIOR CAN BE CORRECTED, BUT MOST CAN BE WITH PATIENCE, PERSEVERANCE, AND EXPERT HELP IF NEEDED)

3.     WHO WILL BE RESPONSIBLE FOR YOUR NEW PET'S CARE?__________________________

4.     ABOUT HOW MANY HOURS A DAY WILL YOUR PET BE ALONE?_____DAYS A WEEK____

5.     WHERE WILL IT BE KEPT WHEN LEFT ALONE? (CRATE, LOOSE INSIDE, KENNEL ETC.)

6.     WHAT TYPE OF I.D. DO YOU PLAN TO HAVE FOR YOUR PET?_________________________

7.    WHAT BRAND OF FOOD DO YOU PLAN TO FEED? _____________________________________

7.  ADOPTION POLICY AND IOWA LAW (FOR PETS FROM POUNDS AND SHELTERS) REQUIRE THAT ADOPTED ANIMALS BE SPAYED OR NEUTERED.  DO YOU AGREE WITH THIS?   

YES______     NO_______

8. ARE YOU PREPARED TO GIVE YOUR NEW PET PLENTY OF TIME (AT LEAST TWO WEEKS IN MOST CASES -- POSSIBLY MORE IF YOU HAVE OTHER PETS) TO ADJUST TO ITS NEW HOME? 

                YES _____     NO _____

9.  WOULD YOU CONSIDER ADOPTING TWO DOGS FOR COMPANIONSHIP -- ESPECIALLY IF THERE IS OFTEN NO ONE HOME?     YES ______     NO ______

        I CERTIFY THAT THE INFORMATION I HAVE GIVEN IS TRUE AND AUTHORIZE INVESTIGATION OF ALL STATEMENTS MADE ABOVE.  I UNDERSTAND THAT THE POUND HAS THE RIGHT TO REFUSE ANY REQUEST FOR ADOPTION.  IN ADDITION I GIVE PERMISSION TO THE POUND AND THEIR ASSOCIATE FACILITIES TO SHARE INFORMATION ABOUT ME THAT MAY BE OBTAINED DURING INTERVIEWS, REFERENCES CHECKS AND HOME VISITS WITH OTHER HUMANE ORGANIZATIONS.

_______________________________________________                  ______________________________

ADOPTER                                                                                             DATE