Minnesota Basset Rescue Home Visit Form
Please complete after doing your home visit on a potential adopter.
Email address *
Volunteer Contact information
Name *
Your answer
Address *
Your answer
Phone Number *
Your answer
Adopter Contact Information
Adopter Name (s) *
Your answer
Adopter Address *
Your answer
Adopter Email Address
Your answer
Adopter Phone Number *
Your answer
Name of Dog(s) interested in (if applicable).
Your answer
General Home Description
This section gives us an idea of the potential adopters home, is important if there is any issues we may want to address, or something that would affect a dog getting adopted at this residence.

Please check one (if applicable)

Is the home clean?
Description/Comments:
Your answer
Stairs
How many stairs?
Your answer
Other dogs in the house?
Descriptions/comments
Your answer
Damage to house by dogs?
Descriptions/comments
Your answer
Areas in house closed to dogs?
Descriptions/comments
Your answer
House plants - Poisonous?
Descriptions/comments
Your answer
Fencing & Yard Description
This will help us understand what the potential adopters outdoor yard looks like and how dog friendly it is.
Is there a fence?
If there is a fence, describe fencing materials:
Your answer
Is the yard shaded?
Explain:
Your answer
Will digging create a problem with landscaping?
Explain:
Your answer
Are there places the dog could leap off a deck or porch and injure itself?
Explain:
Your answer
Is there anything stacked near the fence that the dog could climb on to get out?
Explain:
Your answer
Are there potential escape routes? (low places in fence, evidence of digging, holes in fencing, loose or too high gates)
Explain:
Your answer
If so, did you point out to the adopter, how do they react?
Your answer
Do you think they will fix the problem?
Description/comment
Your answer
Are there locks on the gates (against children & thieves)?
Descriptions/comments
Your answer
Living arrangements
Descriptions/comments
Where will the dog be when company comes?
Your answer
Where will the dog spend the night?
Your answer
Where will the dog spend the day?
Your answer
Check the day area for doghouses, beds, or crates?
Your answer
How is waste removed?
Your answer
Does the area look recently cleaned?
Hazards to Dog Indoors
Please check one (If applicable)
Is there evidence of small children? (Remind adopter that the dog could destroy toys if not put away)
Descriptions/comments
Your answer
Small trash cans?
Descriptions/comments
Your answer
At counter level? (Point them out to adopter)
Descriptions/comments
Your answer
Are there exposed electrical cords? (Point them out to adopter)
Descriptions/comments
Your answer
Are there chemicals in the garage, basement or storage areas? (Point them out to adopter)
Descriptions/comments
Your answer
Does the dog have access to these areas?
Descriptions/comments
Your answer
Do the furnishings of the house appear to be dog proof? (glass objects, or dried flowers at low levels, expensive rugs or furniture that could be knocked over easily) If so, point these out to adopter.
Descriptions/comments
Your answer
How is trash handled in the home?
Your answer
Can the dogs get into the cans? (If so point out to adopter)
Ask how long it takes to get to the nearest emergency pet hospital:
Your answer
Interaction with Current Pets
(if no pets us N/A)
Are current pets well socialized?
Descriptions/comments
Your answer
Are they reasonably clean?
Descriptions/comments
Your answer
Are they hand shy in any way?
Descriptions/comments
Your answer
Can you touch ears & tails?
Descriptions/comments
Your answer
Are they friendly?
Descriptions/comments
Your answer
How do they react towards their owners?
Your answer
Do they respond to commands?
If not, how does the owner handle it?
Your answer
Do you feel the adopter will love & care for the dog properly?
Descriptions/comments
Your answer
Do you feel this home will provide a permanent home for the dog?
If no, Why?
Your answer
If this were your dog, would you do this adoption?
If no, why?
Your answer
Wrap up
Fill out the follow and sign form
Should we allow this potential adopter to adopt a dog from MNBR?
Your answer
Any further comments or observations?
Your answer
Signature of Home Visitor *
Your answer
Date *
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