Home Safety Visit Report Volunteer InformationPulls from logged in, user’s profileVolunteer Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Date of Home Visit(Required) MM slash DD slash YYYY Did you read the Home Safety Visit Procedures prior to your visit?(Required) Yes No Did you take the Home Safety Hazard Checklist to the visit to use as a guideline?(Required) Yes No Applicant InformationApplicant Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reason for Application(Required) Adopt a dog from CPCRN Foster a dog from CPCRN Foster and adopt a dog from CPCRN HouseholdWere all family members present?(Required) Yes No Who was not able to attend or only attend briefly?(Required)Describe the behavior of adults among themselves and to any other pets or children.(Required)How do they interact with each other? Do they express basic considerations and caring to their spouse, children, and other pets?Were there any children in the household?(Required) Yes No Describe the behavior of any children(Required)Do the children seem as if they would be respectful to pets? Will the adults monitor the children’s behavior with the dog? Do the children listen to the parents? Do any members of the household have any special physical needs that we would need to consider?(Required)Such as the use of a respirator, wheel chair, crutches, hard of hearing, blind where CPCRN should consider a dog with the capability to be a special needs dog Yes No Please explain any special physical needs(Required)Are ALL members of the family are equally excited about getting a rescue dog?(Required) Yes No Please Explain(Required)Does the applicant appear to be willing and financially able to care for the dog in later years?(Required) Yes No If you sense a financial concern on their part, please explain.(Required)NeighborhoodDescribe the applicant's street (busy, quiet, in-between):(Required)Describe the setting (rural, suburban, urban):(Required)Are there any dogs or other animals that live adjacent to this property?(Required) Yes No List type and describe how they are contained:(Required)Did you see any stray dogs or other animals in the immediate neighborhood during your visit?(Required) Yes No Describe what was seen:(Required)Front Yard FencingPlease select the type of FRONT yard that is at the home(Required) No Front Yard Front Yard with no Fencing Partially Fenced Front Yard Fully Fenced Front Yard Describe the fence (height, type, condition)(Required)Is there a lock on the gates of any of the fences?(Required) Yes No Do you feel the fencing is able to properly contain a Cairn terrier without repairs or restructure?(Required) Yes No Back Yard FencingPlease select the type of BACK yard that is at the home(Required) No Back Yard Back Yard with No Fence Partially Fenced Back Yard Fully Fenced Back Yard Describe the fence (height, type, condition)(Required)Is there a lock on the gates of any of the fences?(Required) Yes No Do you feel the fencing is able to properly contain a Cairn terrier without repairs or restructure?(Required) Yes No Understanding of CPCRN Policies on Fences and LeashesDid you get the impression that the applicant uses “electric fencing” or tie-outs?(Required) Yes No Did you get the impression that the applicant fully understands that Cairns can never be off leash?(Required) Yes No Additional Home InformationDoes the applicant have a swimming pool, fishpond, lake or other body of water on their property?(Required) Yes No Please describe any body of water on the property(Required)Describe the condition of the home (for example, in good repair, clean, neat, sloppy, cluttered):(Required)Will the dog have access to a garage or basement?(Required) Yes No Describe the garage or basement (e.g., in good repair, clean, no debris on the floor, hazardous substances out of reach of the dog):Do any members of the household have a hobby room or workshop? *(Required) Yes No Please describe by type and list any safety concerns a dog may face:PREPARING FOR DOG'S ARRIVALIn which room will a new dog sleep and what will be used as bedding:(Required)Is there a crate available?(Required) Yes No Describe the size and type:Did you make them aware that a crate is mandatory? Yes No Is there a current dog?(Required) Yes No In which room does the current dog sleep and what is used as bedding?(Required)Where is the current dog kept when home alone?(Required)Describe the current condition of the dog (clean and groomed, in need of grooming, overweight, friendly, unsociable).(Required)Does the applicant have other pets (e.g. cats, rodents, fish, reptiles, birds)?(Required) Yes No Describe and state the condition of these pets. In addition, if there is a tank or cage, does it appear clean or if there is a cat litter box, does it appear fresh?(Required)Are there dog toys available?(Required) Yes No Describe available toys:(Required)Do you feel they plan on getting toys?(Required) Yes No REVIEW OF THE HAZARD CHECKLISTDid you notice any hazards?(Required) Yes No Describe in full any hazards that you may have seen in the applicant’s home by room, area of home and type of hazard:(Required)When you made the applicant aware of the hazards, describe the reactions of the applicant. Were they willing to listen to your suggestions? Did they seem concerned and willing to make changes?(Required)OTHER COMMENTSGut feelings often carry a lot of weight in our decision to place a dog with an applicant. Would you feel comfortable leaving your dog with the applicant and feel that the dog would be safe if you needed to?(Required) Yes No Please explain. (Remember, even great people can be wrong for a specific breed of dog):(Required)You have been our eyes and ears for this phase of the adoption. What are your impressions of this family and the life that one of our rescue dogs would have with them?(Required)CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
