Placement Questionnaire

Placement Questionnaire
Completing this form does not guarantee Furry Friends Network will be able to place your dog/ cat in our foster program or give assistance in helping to rehome your animal. This form will allow Furry Friends Network to assess your pet's background, personality and needs. A time will be scheduled for us to meet you pet should the review of this form determine that is necessary. If we are able to accept your pet into our program, we will need medical records (to include a rabies certificate, vaccine certificate and spay/neuter certificate (as applicable).

Please note, Furry Friends Network will consider Owner Surrendered animals only from the Central Pennsylvania area.
Animals Name
Species (dog/cat)
Breed
Color/Markings
Approximate date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Weight
Sex
Altered (spayed/neutered)
Date of surgery

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of most recent rabies vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date rabies vaccine due

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(If your animal's rabies vaccine was given outside of PA, your animal will need a health certificate in order to be transported into PA)
Date of most recent distemper vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date distemper vaccine due

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of most recent bordatella vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date bordatella vaccine due

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of most recent lyme vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date lyme vaccine due

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of most recent leptospirosis vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date leptospirosis vaccine due

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Feline Aids/Leukemia Test

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Result
Date of Canine Heartworm/Lyme Test

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Result
Date of most recent physical examination

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is heartworm preventative given monthly?
If so what brand is given
Is flea preventative given monthly?
If so what brand is given
Declawed
Please describe any existing or resolved medical conditions. Please note if this animal has been used for breeding purposes had major surgery other than sterilization or been diagnosed with any hereditary diseases
When was this animal last seen by its Veterinarian? (please note reason for visit)
What medications or supplements is your animal currently taking (Explain)
Veterinary Practice Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please call the veterinary clinic to provide give permission for one of our volunteers to obtain medical records.

**A complete medical history needs to be given to Furry Friends Network prior to the animal surrender**
Owners Personal Information
Owners Name
Co-Owners Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Format: (000) 000-0000.
Email Address
example@example.com
Background information on Animal
Please describe fully why you want to rehome your animal
Did you adopt this animal from another organization?
If yes, have you contacted that organization?
Did you purchase this animal or get this animal through a thirdparty
How long have you had the animal
Is this animal in any physical danger at this time? (Explain)
What is the maximum time you can continue to keep the animal?
What brand and variety of food do you feed your animal? (i.e. Purina ProPlan Chicken and Rice Adult)
How much and how often is your animal feed?
Is this animal completely housebroken/litter trained?
If the animal has accidents, how often do they occur? (Explain)
If you are looking to place a cat, has your cat ever gone to the bathroom outside of the litter box? (Explain)
Is your animal kept outside? (Explain)
Is your dog crate trained?
How many hours does your dog spend home alone?
Is the dog crated or loose in the house?
Temperament
Has your animal ever bitten someone or attempted to bite someone? (Explain)
Does your animal growl or act aggressively at people or other animals? (Explain)
Has your animal been socialized with small children (please note ages of children and how much time is spent with them)? (Explain)
How does your animal react around small children? (Explain)
Does your animal have any dislikes? (Explain)
Does your animal get along with other dogs, cats and small animals (please note any aggression)
How is your animal in the car?
Does your animal let you trim its nails?
Does your animal let you touch its feet, face and belly?
Does your animal have any formal obedience training?
What is the highest level of formal obedience training you have completed with your animal? (Explain)
Does your animal have any issues sharing its toys with other animals or humans? (Explain)
Does your animal have any issues with animals and humans walking by or being in close proximity when it is eating?
How active is your dog? (Explain)
Is your animal destructive? (Explain)
How does your animal walk on a leash?
Is your dog reactive to other dogs or people when walking on a leash?
Does your animal have any fears? (ex. lightening, loud noise, etc.) (Explain)
Does your animal have any separation issues (breaking out of crates, chewing up furniture when left alone, etc?
Please describe any special likes or dislikes you feel will be beneficial for Furry Friends Network to be aware of in placing your pet
Living Environment
Where is your animal kept when you are not home?
Where does the animal sleep?
If you are looking to place a dog, has your dog lived with other dogs?
If you are looking to place a dog, has your dog lived with cats?
If you are looking to place a cat, has your cat lived with dogs?
If you are looking to place a cat, has your cat lived with other cats?
What are the ages of the people living in the house?
How do you exercise your animal (note the amount of time the animal is exercised each day)?
Is your yard fenced (please note type of fence)?
Form completed by
Relationship to Animal
Address
Home Number
Work Number
Cell Number
Email Address
example@example.com
Someone will contact you within 48 hours of receipt of this questionnaire
Should be Empty:

Placement Questionnaire

Owners Personal Information

Background information on Animal

Temperament

Living Environment