Date of Visit

Dog(s) being considered

Applicant's Name

Address

City, State, Zip

Home Phone

Other Phone

Other Phone Type Select Cell Work Other

Email

Identify all household members and ages.

Who will be the primary caretaker and are they physically able to care for a dog?

Type of Home Select House Apartment Condo Townhouse Trailer Other

Rent or Own Select Rent Own

Number of levels

Describe the flooring throughout the home Carpet/Tile/Hardwood/etc.

Cleanliness of home

Describe each door that leads to the outside Door location - Potential for Escape (Low/Medium/High) & Description - Potential for Harm (Low/Medium/High) & Description

How is applicant planning to prevent escapes through higher risk doors?

Will a dog be allowed on the furniture? Yes No

Will a dog be blocked from entering rooms/portions of the home? Yes No

How will the applicant block access? (Doors/Baby Gates/etc.)

Other comments on the condition of the home

Describe the street Select Busy Quiet In Between

Describe the setting Select Rural Suburban Urban

Closest busy road and how far away it is

Is there a yard? Yes No

Condition of the yard

Is the yard securely fenced? Yes No

Height of fence Select Underground Under 4 ft 4 ft 5 ft 6 ft Over 6 ft

Type of fence Select Wood Chain Link Brick Invisible/Electric Other

Are there any potential issues? (Holes/Fence too short/Fence too high off ground/Dig-able areas/Gate easily pushed open especially at the bottom)

How does applicant plan to address these issues?

If no fence, describe tie-out or walking situation/area.

Besides the yard/tie-out, how/where does applicant plan to exercise dog?

List all current pets. Include Name/Type/Breed/Gender (Spayed/Neutered)/Age/How long owned/Where kept/Physical appearance/Temperament

Are there any potential integration issues with a new dog?

Are all household members present? If no, who and why?

Describe the behavior of the family members among themselves

Describe the behavior of the adult household members to pets

Describe the behavior of the children to pets

What does the applicant know/not know about what a dog requires annually in veterinary care? (Including Vaccinations/Heart worm test/Heart worm protection/Flea-tick protection/Fecal test)

What negative Shiba Inu attributes is the applicant aware/not aware of? (Including Escaping/Aloofness/Dog aggression/Child uncertainty/Stubbornness)

How does the applicant plan to address the grooming needs of a Shiba Inu? (Including Bathing frequency/Blowing coat/Brushing/Nail Clipping/Teeth Brushing)

If applicant has dogs: What brand/formula and how much food do they currently feed, what is the feeding schedule, are any supplements given? (Including Fish oil/Glucosamine/Chondroitin/etc.)

For the adopted dog: What and how much food will they feed, what will the feeding schedule be, will any supplements be given?

What foods is the applicant aware/not aware of that are a dangerous for dogs to eat? Chocolate/Caffeinated Drinks, Onion family (chives, radishes, etc.), Grapes/Raisins, Mushrooms, Macadamia Nuts/Walnuts, Tomatoes, Apple Cores and Avocado Pits are all toxic for dogs. Cooked bones can splinter and cause damage to internal organs. Nutmeg causes tremors, seizures and death. Raw Eggs can cause salmonella poisoning.

What annual costs for maintaining a dog is the applicant aware/not aware of? (Including Vet care both expected and unexpected/Food/Boarding/Toys and chews/etc.)

Does the applicant understand the need/importance of positive based obedience training, with all family members, with a new dog at any age?

What common medical problems is the applicant aware/not aware of, and do they know how to address them? (Including Allergies/Hot spots/Glaucoma/Luxating Patellas)

Are there any other circumstances that need to be investigated further?

Do you feel a rescue dog will be well loved, cared for and safe if adopted to this applicant?

Home visit evaluator

Email

Date of Form