Dog SURRENDER Questionnaire (Personality Profile)

Dog Surrender Questionnaire

The Baltimore Humane Society CANNOT ACCEPT FOUND/STRAY ANIMALS. If the dog you need to surrender is a stray and/or you are not the owner, you must contact Baltimore County Animal Services at 410-887-7297.
*Please note at this time we are operating on a waiting list. We ask you only submit a form if you are able to continue caring for your dog for at least the next 2 weeks.*

If you adopted your dog from The Baltimore Humane Society, please call the Adoption Center at 410-833-8848 Ext/Opt 2 to schedule your return appointment.
Where did you originally obtain this dog?*

Adopted from BHSBreederPet StoreFriend/PrivateFound/StrayFostered for BHSOther Shelter/RescueOther
Name of Shelter/Rescue where you adopted this dog.*
BARCS, MDSCPA, Baltimore County Animal Services, etc.
Have you contacted the shelter/rescue where you adopted this dog from?*

YesYes, but the won't call me backNo, I don't want to contact them
I understand that submitting this form is not a guarantee that I will be able to surrender my pet to the Baltimore Humane Society. Intakes are done on a case-by-case basis, and can only be made after we evaluate your pet. We will contact you with next steps.*

I understand
I understand that The Baltimore Humane Society is a non-profit organization and that I am responsible a surrender fee of $85 for a dog or litter of puppies who are not neutered/spayed or $50 for a dog who is already neutered/spayed.*

I understand
Owner Information
First & Last Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Apt/Unit/Suite #

CityState / Province

Postal / Zip Code
General Pet Information
Dog's Name*
Charlie, Luna, Ginger, etc.
Dog's Age*
3 days, 3 weeks, 3 years, etc.
Dog's Breed*
Pitbull Terrier, Labrador Retriever, Mixed Breed, etc.
Dog's Sex/Gender*

FemaleMaleI don't know
Has your dog been spayed/neutered?*

YesNoI am not sure
How long have you owned this dog?*
3 days, 3 week, 3 months, 3 years, etc.
Why do you need to surrender your dog to BHS? (please check all that apply)*

MovingHousehold member is allergicLandlord restrictionsNo longer have timeSeparation/DivorceSheds too muchBehavior concernsBite historyDoesn't get along with other household petsEscapes the yard too muchHouse training issuesPet's medical problemsFinancial reasonsPersonal medical problemsDeath of ownerHas too much energyDoesn't listenDestructive when left home alone
Please provide more detail as to why you need to surrender your dog to BHS.*
Bite History
Has your dog ever bitten a person?*

YesNo
Did the bite to the person break skin?*

YesNo
Did the bite to the person draw blood?*

YesNo
When did this bite occur? (If you don't know the exact date, please give us your best estimate)*
If the bite occurred while breaking up a dog fight, please explain what happened below.
If the bite occurred while at the vet or groomer, please explain what happened below. *
If the bite occurred during an instance with food or bones, please explain what happened below.
If medical treatment was necessary for this bite, please explain below.
Has your dog ever bitten another animal?*

Yes, another dogYes, a catNo
Since your dog has bitten another dog, we need more information. Please be as detailed as you can when describing the circumstances of the bite incident.*
Did either dog have to be seen by a veterinarian due to this altercation?*

YesNoUnknown
Was a bite report filed?*

YesNo
Household Information

What types of animals has your dog lived with? (check all that apply)*

No other animalsDogsCatsSmall animals (rabbits, guinea pigs, etc.)
What brand of food does your dog eat and how much/how often?*
How much exercise does your dog get daily?*

NoneLess than an hour1-2 hours3-4 hours
What is your dog's main form of exercise? (check all that apply)*

No exerciseLeash WalksYard PlayHouse PlayDog PlayDoggy Daycare
How is your dog contained when outdoors? (check all that apply)*

Fenced-in YardPen/KennelLeadNot confined/roamed freelyElectric Fence
How tall is the fence and what material is it made of?*
How long is this dog left alone in your home on a daily basis?*

Never1-3 hours4-8 hours9-12 hoursOver 12 hours
Where is your dog left when home alone?*

Has never been left home aloneFree range of the houseCrate/kennelOne roomGarage/basementOutside in fenced-in yardOutside on leadOutside in kennel/dog house
If your dog has been crated while in your care, please describe what you've seen/heard while they've been crated.
Example: barking, whining, doesn't seem to settle easily, etc.
Where does your dog sleep at night? (check all that apply)*

Loose in houseCrate or on dog bedIn child's room or bedIn adult's room or bedOn couch or chairIts own roomGarageOutside
General Behavior

Does any of the following frighten your dog? (check all that apply)*

MenWomenBabies/toddlersTeenagersStrangers/visitorsVetGroomerRiding in the carThunder/lightningFireworks/loud noisesSudden movementVacuumNothing frightens my dog
What are your dog's favorite types of toys? (check all that apply)*

No interest in toysTennis ballsFrisbeesPlastic/rubber squeaky toysRope toysStuffed/squeaky toysNylabonesKongs
How does your dog typically behave when left alone in the yard? (check all that apply)*

Never outside aloneFine/relaxedBarksDigs holesEscapesOther
How many times since ownership has your dog escaped your yard?

NoneOnce2-3 times4 or more times
If your dog escapes your yard, what typically triggers them? (check all that apply)

Nothing, just likes to roamDog walking byStray cat walking bySee a wild animal (squirrel, deer, rabbit, etc.)Car driving bySees a person walking by
If your dog escapes the yard, how would they do it? (check all that apply)*

Jumped/climbed the fenceDug underneath the fenceBroke through the gateGate was left openDoor was left open and we don't have a fenced-in yard
Behavior with Children
Does your dog currently live with children under the age of 12 years old?*

YesNo
How do your children interact with your dog? (check all that apply)*

Gently/respectfullyChasesLays/sits on dogHugs/snuggles/sleeps withPlays fetch/tugRoughhouses/wrestlesTug ears/tailGrabs fur/pawsDresses up
How does your dog behave around your children? (check all that apply)*

Indifferent/ignoresAffectionate/playfulJumps up onHerds (nips at heels)Plays roughTolerates, but has a limitNervous/fearfulGrowls/snaps
Do children visit your home regularly?*

YesNo
If tolerates but has a limit, is nervous, fearful, growls or snaps, please explain the situation leading up to these behaviors below.
How old are the children who visit your home regularly?*
please select one option above
Would you recommend your dog live in a home with children or where they visit regularly? Please elaborate on your reasoning to help us better understand your dog's needs.*
Behavior with Other Pets

Would you recommend your dog live in a home with other dogs? Please elaborate on your reasoning to help us better understand your dog's needs.*
Would you recommend your dog live in a home with cats? Please elaborate on your reasoning to help us better understand your dog's needs.*
Manners/Training
Is your dog house-trained?*

YesAlmost, occasional accidentsNo
If your dog has accidents in the house, when do they typically occur? (check all that apply)*

When dog is not kept on scheduleWhen dog is not closely supervisedWhen dog is outsideWhen dog is overexcitedWhen dog asks to be let out and is ignoredDon't know
What was your typical response to your dog having accidents in the house? (check all that apply)*

Consulted vetConsulted dog trainerConfined dog when not supervisedKept dog outsideRubbed dog's noise in itYelled at dogSpanked dogActed "mad" at dogNo response
Has your dog had any obedience training?*

Yes, obedience classesYes, trained by ownerNo
Please describe how you've trained your dog while in your care?*
Have you used any kind of electric/shock collar on your dog?*

YesNo
If yes, what is the electric collar used for? (check all that apply)*

Outside invisible fenceTeach basic commandsControl barkingModify major behavior problem
Please explain the major behavior problems you were using the electric collar to modify?
How do you typically respond when your dog misbehaves? (check all that apply)*

Dog never misbehavesNo responseYelled at dogPut dog in crate for timeoutPut dog in room for timeoutPut dog outside for timeoutSpanked dogConsulted trainerConsulted vet
Does your dog respond to any verbal commands? If yes, check all that apply.*

NoneSitDownStayComeLeave itDropOffHeel
Medical History/Vet Care
Have you taken your dog to a veterinarian since ownership?*

YesNo

What was the last vet visit for? (check all that apply)*

Never been to the vetAnnual check-up/vaccinesIllness/injury
Please elaborate on the illness/injury your dog needed to visit the vet for.*
How does your dog behave at the vet? (check all that apply)*

Fine/relaxedNervous, but toleratesGrowls/snapsHas to be muzzledHas to be sedated
Does your dog have any current or past medical issues? If yes, please describe below.*
If you'd like to include some of your favorite photos of your dog, we'd greatly appreciate it!

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Should be Empty:

	Female	Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60 years +

	N/A	Barks	Chases	Lunges	Growls/Snaps	Nothing
Pedestrians
Cyclists
Cars/Buses
Wildlife

	Never tried/encountered	Barks	Growls	Cowers	Nothing
Another pet approaches their food bowl
Another pet approaches their toys/bones
Person approaches their food bowl
Stranger approaches front door
Doorbell rings/knock on door
Stranger approaches owner

	Never tried	Loves	Tolerates	Cowers	Growls	Urinates	Destructive
Being Pet
Nail Trim
Car Rides
Home Alone

	N/A	Playful/friendly	Ignores	Rough	Chase with Intent to harm	Fights
Dog
Cats
Small Animals

	N/A	Playful/Friendly	Cower	Bark	Growl	Lunge
Dogs
Cats

	Vet Hospital/Clinic Name	Vet Hospital/Clinic Phone Number	First & Last Name on Vet Account
Vet #1
Vet #2

Dog Surrender Questionnaire

Owner Information

General Pet Information

Bite History

Household Information

General Behavior

Behavior with Children

Behavior with Other Pets

Manners/Training

Medical History/Vet Care