Dog Surrender Pre-screening Questionnaire

Dog Surrender Pre-screening Questionnaire
KC Pet Project only accepts animals from Kansas City, Missouri. If you are a Kansas City, Missouri resident in need of assistance, please complete the following form. You should submit one form per pet you are requesting to surrender or relinquish to KC Pet Project.

It is important that the answers provided for surrender questionnaires and assessments are honest and detailed. This information is all KC Pet Project has to help set the pet up for success while in our care and in-depth information allows us to find the best outcome for the pet, including placement options and matchmaking for adoptions.

Once you have submitted your questionnaire, a Pet Support Specialist will contact you to gather any additional information, discuss what options are best for the pet, and/or schedule an intake appointment for the pet to be surrendered to KC Pet Project at the Kansas City Campus for Animal Care. If you have any questions, please call 816-683-1383. Thank you.
Name:

First NameLast Name
Preferred Name:
Pronouns:

Other
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Preferred method of contact:
Preferred time of contact:
Preferred language:

Other
Have you used KC Pet Project services before?
- Dog Name:
- Breed:
- Age and/or Birthday:
- Weight:
- Sex:
- Color(s):
- Distinguishing Markings:
- How long have you had your dog?
- Optional: Please add a photo of your pet:
  
  JPG, PNG, GIF or PDF only. 5MB or less.
  Cancelof
- What is the reason for needing to re-home your dog?
  
  Other
- Have you taken any steps to resolve or remedy the reasons that are causing you to re-home your dog?
- If yes, please describe:
- Are you willing to temporarily foster your dog until it can be adopted?
- If yes, for how long?
- Are you interested in private re-homing through our Supported Re-homing Services?
- If we could provide you with any of the following resources, would you be able to keep your dog?
  
  Other
- Please describe what type of medical assistance:
- Research has shown a correlation between the mistreatment of animals and the presence of domestic violence within households. Your answers to the following questions help our team partner with you and connect you to services and resources available to you.
- Has your current/former partner harmed or threatened to harm your pet?
- Has your current/former partner harmed or threatened to harm you?
- Do you feel unsafe in your home because of a current/former partner?
- We're here to help. Learn more about our supportive programs.
- Has your dog been vaccinated in the last 12 months?
- Is your dog microchipped?
- Microchip Number:
- Primary Veterinarian (name, clinic, and contact information):
- Is your dog on any medications or special diet?
- If yes, please describe:
- What brand of dog food do you feed your dog?
- How often is your dog fed?
  
  Other
- Does your dog have a favorite type of treat?
- If yes, what types of treats does your dog like?
- Does your dog have any allergies or medical conditions?
- If yes, please describe:
- Where did you get your dog from?
  
  Other
- Animal shelter or rescue name:
- Where has your dog been living primarily?
  
  Other
- How long is your dog left alone, without people, on a typical day?
- Does your dog show any of the following signs of anxiety or abnormal behavior when left alone for short periods of time?
- Is your dog housetrained?
- Please explain more about your dog's level of housetraining:
- What toys and games does your dog like?
  
  Other
- When your dog plays, does he/she typically:
  
  Other
- What commands does your dog know?
  
  Other
- Is your dog afraid of anything?
- Please describe:
- Is your dog allowed on the furniture?
- Where does your dog normally sleep at night?
  
  Other
- Does your dog escape your property?
- How does your dog escape the property?:
  
  Other
- Please describe:
- Please tell us your dog's "bad habits". If there aren't any, enter "none".
- Please tell us something interesting, unique or fun about your dog, his/her traits, or personality that we can tell potential adopters:
- What other animals has your dog lived with?
  
  Other
- Gender of dog(s)
- Size of dog(s)
- Age of dog(s) (please specify months/years):
- Has your dog ever reacted to a FAMILIAR PET by growling, showing teeth, snapping, or biting during any of the following situations:
- Please describe the activities that led up to any snap or bite occurrence with a familiar pet:
- Has your dog ever reacted to an UNFAMILIAR PET by growling, showing teeth, snapping, or biting during any of the following situations:
- Please describe the activities that led up to any snap or bite occurrence with an unfamiliar pet:
- Has your dog ever attacked another animal resulting in severe injury or death?
  
  Other
- Please describe the activities that led up to any occurrence of injury or death of another animal by your dog:
- Has your dog ever reacted to other animal types by growling, showing teeth, snapping, or biting?
- Please describe the activities that led up to any snap or bite occurrence with another animal:
- Does your dog usually chase or attempt to chase outdoor cats, squirrels, or other small animals?
- Has your dog bitten anyone in the last ten (10) days?
- If yes, what day and in what city did the bite occur in?
- If yes, please explain any injury that resulted from the bite incident:
- What types of people has your dog lived with?
  
  Other
- What ages were the children or teenagers?
- Has your dog ever reacted to a person by growling, showing teeth, snapping, or biting during any of the following situations:
  
  Other
- Please describe the activities that led up to any snap or bite occurrence with a person or child:
- Has your dog ever inflicted a bite to a person that broke the skin?
- Please describe the activities that led up to any bite occurrence that broke the skin:
- Has your dog ever shown any of the following behaviors when being bathed or brushed, having their paws wiped, or having their harness or collar put on?
- Please describe the activities that led up to any snap or bite occurrence when being bathed or brushed, having their paws wiped, or having their harness or collar put on:
- Is there any other information you would like us to know about your pet that may help us find the best placement options for this animal?
- Other information for best placement options:
- I am the owner or authorized agent/designee for the owner of the animal described above.
- The information provided in this questionnaire is accurate and true to the best of my knowledge.
- I understand that by submitting this questionnaire, it does not guarantee an appointment to surrender my animal(s) to KC Pet Project.
- I acknowledge that by completing this questionnaire I am requesting pet surrender support and/or services through KC Pet Project and that I will be contacted at a later date to discuss my pet(s) and schedule an intake appointment, if necessary.
- DISCLAIMER: KC Pet Project strives to find placement for all animals that enter into our care, however we may elect euthanasia on the animal(s) you are relinquishing if it is determined to be in the best interest of the animal or the organization. We reserve the right to elect euthanasia without notification, if we see fit. Please initial that you understand.
- Signature
- Date
  
  MonthDayYear
  Date
- Should be Empty: