Joplin Humane Society
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Dog Surrender Pre-screening Questionnaire
Joplin Humane Society only accepts animals from Southwest Missouri. If you are a resident of the Southwest Missouri areas and are in need of assistance, please complete the following form. You should submit one form per pet you are requesting to surrender or relinquish to the Joplin Humane Society. It is important that the answers provided for surrender questionnaires and assessments are honest and detailed. This information is all JHS 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 Counselor 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 the Joplin Humane Society. If you have any questions, please call 417-623-3642 ext 3. Thank you.
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Indicates required field
Name
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First
Last
Phone Number
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Pronouns:
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She/Her/Hers
He/Him/His
They/Them/Their
Other
Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Preferred method of contact:*
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Phone
Email
Preferred time of contact:*
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Morning
Afternoon
Option 3
Have you used JHS services before?*
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Yes
No
Dog Information
Dog's name:
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Age and/or Birthday:
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Sex
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Male- Neutered
Male- Intact
Female- Spayed
Female- Intact
I don't know
Weight
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Color(s)
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Dog breed
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Distinguishing Markings:
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Optional: Please add a photo of your pet:
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Max file size: 20MB
Reason for Re-homing Your Dog
What is the reason for needing to re-home your dog?
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Allergic to Animal
Cannot Afford
Death of Owner/Family
Health of Owner/Family
Behavior Challenges
Change in Lifestyle
Health of Animal
Not a good fit with household/living arrangements
Housing Issues- Cost
Housing Issues- Moving/Relocating
Unwanted Litter
Other
Have you taken any steps to resolve or remedy the reasons that are causing you to re-home your dog?
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Yes
No
Are you willing to temporarily foster your dog until it can be adopted?
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Yes
No
If we could provide you with any of the following resources, would you be able to keep your dog?
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Dog House
Outdoor tie-out
Crate
Flea Prevention
Spay/Neuter
Microchip
Collar
Dog Food
Vaccinations
Leash
Behavior/ Training
Pet medical assistance
Pet Rent/ pet deposit assistance
None of these
Other
Are you interested in private re-homing through our Supported Re-homing Services?
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Yes
No
Unsure, give me more informatio
Dog Basic Information
Has your dog been vaccinated in the last 12 months?
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Yes
No
Unknown
Is your dog microchipped?
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Yes
No
Unknown
Primary Veterinarian (name, clinic, and contact information):
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Is your dog on any medications or special diet?*
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Yes
No
What brand of dog food do you feed your dog?
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How often is your dog fed?*
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Once a day
Twice a day
Other
Does your dog have any allergies or medical conditions?
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Yes
No
Unknown
Where did you get your dog from?
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Joplin Humane Society
Newspaper/website
Breeder
Pet Store
Owner rehoming animal
Friend/ relative
Found/ stray
Born in home
Craigslist/ Facebook
Animal shelter/ rescue
Where has your dog been living primarily?
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Indoors confined to a room
Garage
Outdoors on a cable, chain, or tie-out
Indoor free to roam
Outdoors in a fenced yard
Outdoors in a kennel
General Behavior
How long is your dog left alone, without people, on a typical day?
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Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hours
Is your dog housetrained?
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Mostly, has occasional accidents
Only if left alone for long hours
Yes, completely
No, frequently has accidents
Does your dog show any of the following signs of anxiety or abnormal behavior when left alone for short periods of time?
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Excess salivation
Restlessness, agitation or pacing
Whining, barking or howling
Chewing or scratching at the door, windows, curtains, etc. that has results in damage
Destroy household items
Urinates/ defecates
Escapes crate
None of these
Please explain more about your dog's level of housetraining:
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What toys and games does your dog like?
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Balls
Frisbee
Plush Toys
Wrestling
Tug Game
Squeaky Toys
Tug Toys
Fetch
Chase
Unknown
Other
When your dog plays, does he/she typically:
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Jump
Bark
Bite hard
Growl
Bite lightly
Unknown
None of these
Other
What commands does your dog know?
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Sit
Come
Stay
Down
Heel
Shake
Speak
Unknown
None
Other
Is your dog afraid of anything?
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Yes
No
Unknown
Is your dog allowed on the furniture?
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Yes
No
Does your dog escape your property?
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Yes
No
Where does your dog normally sleep at night?
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Kennel
Dog Bed
Owner's Bed
Dog house outdoors
Floor
Couch
Outdoors
Other
Please tell us your dog's "bad habits". If there aren't any, enter "none".Comment
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Please tell us something interesting, unique or fun about your dog, his/her traits, or personality that we can tell potential adopters:
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Behavior Around Other Animals
What other animals has your dog lived with?
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None
Cats
Dogs
Other
Has your dog ever reacted to a FAMILIAR PET by growling, showing teeth, snapping, or biting during any of the following situations:
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Yes, when approached by a familiar pet while in their favorite resting place
Yes, when approached by a familiar pet while playing with or chewing a favorite toy, bone, treat, object, ect.
Yes, when approached by a familiar pet while being walked/exercised on a leash
Yes, when approached by a familiar pet while eating
Yes, when approached by a familiar pet while engaged in another activity
None of these
Please describe the activities that led up to any snap or bite occurrence with a familiar pet:
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Has your dog ever reacted to an UNFAMILIAR PET by growling, showing teeth, snapping, or biting during any of the following situations:
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Yes, when approached by an unfamiliar pet while in their favorite resting place
Yes, when approached by an unfamiliar pet while eating
Yes, when approached by an unfamiliar pet while playing with or chewing on a favorite toy, bone, treat, object, etc.
Yes, when approached by an unfamiliar pet while engaged i another activity
None of these
Please describe the activities that led up to any snap or bite occurrence with an unfamiliar pet:
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Has your dog ever attacked another animal resulting in severe injury or death?
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Yes, other dogs
Yes, cats
Yes, livestock
Yes, small pets (hamster, guinea pig, etc.)
Yes, wildlife (squirrels, etc.)
No, my dog has never reached to another animals as described
Please describe the activities that led up to any occurrence of injury or death of another animal by your dog:
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Has your dog ever reacted to other animal types by growling, showing teeth, snapping, or biting?
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Yes, other dogs
Yes, cats
Yes, livestock
Yes, small pets (hamster, guinea pig, etc.)
Yes, wildlife (squirrels, etc.)
No, my dog has never reacted to other animals as discribed
Please describe the activities that led up to any snap or bite occurrence with another animal:
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Does your dog usually chase or attempt to chase outdoor cats, squirrels, or other small animals?
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Yes
No
Unknown
Behavior Around People
Has your dog bitten anyone in the last ten (10) days?
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Yes
No
What types of people has your dog lived with?
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Infants/toddles
Small Children
Teenagers
Adults- Male
Adults- Female
Other
What ages were the children or teenagers?
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Has your dog ever reacted to a person by growling, showing teeth, snapping, or biting during any of the following situations:
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Yes, when approached by an unfamiliar person of child while in the home
Yes, when approached by an unfamiliar person child while eating
Yes, when approached by a familiar person or child to take away or remove a favorite toy, bone, treat, object, etc.
Yes, when approached by an unfamiliar person or child while being walked/exercised on leash
Yes, when approached by a familiar or unfamiliar person or child while engaged in another activity
No, my dog has never reached to other people as described above
Other
Please describe the activities that led up to any snap or bite occurrence with a person or child:
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Has your dog ever inflicted a bite to a person that broke the skin?
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Yes
No
Unknown
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?
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Fear
Shows teeth/ growls
Snaps
Bites
None of these
Unknown
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?
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Agreement
I am the owner or authorized agent/designee for the owner of the animal described above.
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I agree
The information provided in this questionnaire is accurate and true to the best of my knowledge.
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I agree
I understand that by submitting this questionnaire, it does not guarantee an appointment to surrender my animal(s) to Joplin Humane Society.
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I agree
I acknowledge that by completing this questionnaire I am requesting pet surrender support and/or services through Joplin Humane Society and that I will be contacted at a later date to discuss my pet(s) and schedule an intake appointment, if necessary.
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I agree
Signature
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Date
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Submit
