Dog SURRENDER Questionnaire (Personality Profile)

Dog Surrender Questionnaire (Personality Profile)
**WE ARE CURRENTLY AT CAPACITY AND ARE OPERATING ON A WAITLIST. PLEASE ONLY COMPLETE THIS FORM IF YOU CAN CONTINUE TO CARE FOR YOUR DOG(S) FOR AT THE LEAST THE NEXT 2 WEEKS. If you need more immediate placement, please contact your local county/city shelter.

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 or take that found/stray animal to your local county/city shelter.

BALTIMORE COUNTY ANIMAL SERVICES

BALTIMORE CITY ANIMAL CONTROL

If you adopted this dog from The Baltimore Humane Society, please call the Adoption Center at 410-833-8848 Ext/Opt 2 to schedule your return appointment. You do not need to complete this form. Thank you.
Adopted from BHSFriend/PrivateFamily MemberBreederFound/StrayPet StoreOther Shelter/RescueOnline Pet AdoptionCraigslistAdoption EventOther
Name of Shelter/Rescue where you adopted this dog.*
BARCS, MDSCPA, Baltimore County Animal Services (BCAS), etc.
Yes, but they won't call me backNo, I don't want to contact themYes, and they won't take this dog backYes, but I don't want to take this dog back themOther
Owner Information

We must have the current owner's contact information in order to create an owner surrender contract at time of surrender appointment. Thank you.
Primary Caretaker's Full Legal Name*

First NameLast Name
Email Address*
example@example.com
Primary Phone Number*
Please enter a valid cell phone number.Format: (000) 000-0000.
Secondary Caretaker's Full Legal Name

First NameLast Name
Secondary Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Apt/Unit/Suite #

CityState / Province

Postal / Zip Code
Dog's 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, I don't know, etc.
Dog's Size*
Weight
FemaleMaleI don't know
YesNoI don't know
How long have you been caring for this dog?*
3 days, 3 week, 3 months, 3 years, etc.
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/health concernsDeath of ownerHas too much energyDoesn't listenDestructive when left home alone
Please provide as much detail as possible as to why you need to surrender this dog to BHS.*
Bite History

Towards humans and other animals while in your care
YesNo
YesNo
YesNo
YesNo
YesNoI am not sure
When did the most recent bite incident occur?*
10 days ago, 6 years ago, a few months ago
Medical treatment was necessary for person who was bitDog bit while at vetDog bit while at groomerDog bit while being picked upDog bit while being brushedDog bit while a dog fight was being broken upDog bit while food, treats, bones and/or toys were involvedDog bit while in severe pain due to an illness or injuryDog bit due to an incident involving a childA bite report was filed with your local animal control/health departmentOther
Please give as much detail as possible as to what occurred before, during and after the bite incident, who was involved, and anything you'd like to share regarding the incident.*
Ex: My neighbor's dog was off leash and my dog got bit by the neighbor's dog.
Household Information

NoneLess than an hour1-2 hours3-4 hours5+ hoursOther
No exerciseLeash WalksYard PlayToys/EnrichmentDog Park PlayDoggy DaycareSwimmingHiking/AdventureAgility TrainingRunningOther
Fenced-in YardPen/KennelTie-out/LeadNot confined/roamed freelyElectric FenceOn leash during a walkDog is not allowed outdoorsOther
How tall is the fence in your yard and what material is it made of?*
Ex: 5 foot chain-linked fence/privacy fence, etc.
Never1-3 hours4-8 hours9-12 hoursOver 12 hours
Loose in the houseCrate/kennelOne roomGarage/basementOutside in fenced-in yardOutside on tie-out/leadOutside in kennel/dog houseOther
Has this dog ever been crated?*
I don't knowCrateDog BedChild's bedroom floorChild's bedAdult's bedCouch/chairDog RoomGarageMudroom/BathroomOutsideOther

FEEDING SCHEDULE*

Rows	Food Brand	Feeding Schedule	Food Allergies
Dry Food
Wet Food
Treats

General Behavior

MenWomenBabies/toddlersTeenagersStrangers/visitorsVetGroomerRiding in the carThunder/lightningFireworks/loud noisesSudden movementVacuumNothing frightens my dog
No interest in toysTennis ballsFrisbeesPlastic/rubber squeaky toysRope toysStuffed/squeaky toysNylabonesKongs
Never outside aloneFine/relaxedBarksDigs holesEscapesOther
NeverOnce2-3 times4 or more timesDailyOther
Nothing, just likes to roamDog walking byStray cat walking bySee a wild animal (squirrel, deer, rabbit, etc.)Car driving bySees a person walking byOther
Jumped/climbed the fenceDug underneath the fenceBroke through the gateGate was left openDoor was left open and we don't have a fenced-in yardOther
Behavior with Children
YesNo
Gently/respectfullyChasesLays/sits on dogHugs/snuggles/sleeps withPlays fetch/tugRoughhouses/wrestlesTug ears/tailGrabs fur/pawsDresses up
Indifferent/ignoresAffectionate/playfulJumps up onHerds (nips at heels)Plays roughTolerates, but has a limitNervous/fearfulGrowls/snaps
YesNo
How old are the children who visit your home regularly?*
please select one option above
If tolerates but has a limit, is nervous, fearful, growls or snaps, please explain the situation leading up to these behaviors below.
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 this dog's ideal environment/home.*
Behavior with Other Animals
No other pets in the homeDogsCatsRabbitsGuinea PigsReptilesBirdsFishRodents/mice/ratsOther

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
YesAlmost, occasional accidentsNo
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 knowWhen dog is not cratedOther
Consulted vetConsulted dog trainerConfined dog when not supervisedKept dog outsideRubbed dog's noise in itYelled at dogSpanked dogActed "mad" at dogNo response
Yes, professional obedience classesYes, trained by ownerNo
Name and Location of Dog Training Business Used
Canines at Training in Reisterstown, etc.
Please describe in detail how this dog has been trained while in your care?*
YesNo
Outside invisible fenceTeach basic commandsControl barkingModify major behavior problem
Please explain the major behavior problems you were using the electric collar to modify?
Dog never misbehavesNo responseYelled at dogPut dog in crate for timeoutPut dog in room for timeoutPut dog outside for timeoutSpanked dogConsulted trainerConsulted vet
NoneSitDownStayComeLeave itDrop ItOffHeelPlaceFind ItWaitSpeakOther
Medical History/Vet Care
YesNoI don't know

Never been to the vetAnnual check-up/vaccinesIllness/injury
Please elaborate on the illness/injury that required the most recent vet visit for this dog.*
Fine/relaxedNervous, but toleratesGrowls/snapsHas to be muzzledHas to be sedatedPancakes on floorCowers/runs awayTries to biteUrinates
Does this dog have any current or past medical issues? If yes, please describe below.*
Is there anything you think a potential adopter would like to know about this dog? If so, please be as detailed as you'd like!
If you'd like to include some of your favorite photos of your dog, we'd greatly appreciate it!

Cancelof
If your dog has ever been crated, please describe what you've seen/heard while they've been crated.
Example: barking, whining, doesn't seem to settle easily, etc.
I understand
I understand
Should be Empty:

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

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

Rows	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

Rows	Animal Type	Age	Sex	Size	How did they interact/behave?
Pet Number #1
Pet Number #2
Pet Number #3
Pet Number #4
Pet Number #5

Rows	Vet Hospital/Clinic Name	Vet Hospital/Clinic Phone Number	First & Last Name on Vet Account
Vet #1
Vet #2
Vet #3

Rows	Never encountered	Friendly	Cowers	Barks	Growls	Lunges	Nothing
Men
Women
Children

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

Dog Surrender Questionnaire (Personality Profile)

Owner Information

Dog's Information

Bite History

Household Information

General Behavior

Behavior with Children

Behavior with Other Animals

Manners/Training

Medical History/Vet Care