Texas Old English Sheepdog Rescue, Inc.

  
   

Owner Surrender Questionnaire

  
   

Text in blue are required

  
  Date:   Dog's name:   Age:
  Present Owner:   Street Address:   City, State, Zip code:
  Email address:            
  Home / Cell Phone:   Work Phone:      
  Children:   how many:   ages:
  Other animals:   how many:   Types:
  Where did you get this OES?   Name of Breeder/pet store:   Address /phone of breeder/pet store:
  How long have you owned the dog?   Reason for giving up:      
  Sex:   Spayed:   Neutered:
  AKC records:   Coat length (puppy cut), full length, shaved?   Last Groomed? (date)
  Groomer's name:   Groomer's  street address:   Groomer's  city, state, Zip:
  Groomer's phone:  
  Does dog need to be groomed?   matted:   bath:
  How does dog react to being groomed?   Food Type:   Feeding Schedule:
  Housebroken?   If yes, how long can dog be left?   What signal does dog give?
  Is dog on lead or left alone for "potty" ?            
                 
   

Any information about the previous owner will be appreciated, enter below: 

            
  Previous owner's name:   Address:      
  Phone (home):   Phone (work):      
  Children:   How many?   Ages:
  Other animals:   how many:   Types:
  Reason for giving up:            
  Veterinarian:   Vet. address:   Telephone:
                 
   

Commands dog responds to: Please answer either
(always - sometimes - never) 

    

 

      
  Sit:   Down:   Stay:
  Come:   Heel:   Others:
  Is dog leash trained?   if yes enter (good -fair - bad):   Is your yard fenced?
  Is dog allowed to run loose?   On leash at all times?   Can you take dog for a walk off leash?
Comments:
                   
   

Health History

      

 

      
  Do you have all medical records with you?              
  Your veterinarian's name:              
  Address:              
  Phone number:              
  Rabies:   Tag#: Rabies tag Date:    
  Distemper:       Distemper Date:    
  Hepatitis:       Hepatitis Date:    
  Parainfluenza:       Parainfluenza Date:    
  Parvovirus:       Parvovirus Date:    
  Leptospirosis:       Leptospirosis Date:    
  Bordetella:       Bordetella tag Date:    
  Corona:       Corona Date:    
  Fecal:       Fecal Date:    
  Heartworm date tested:  

Heartworm last given:

Heartworm Type:

    
  Weight:              
   

 

              
  Please describe general health - including history of arthritis, colitis, skin problems, allergies, etc. Also, urine & bowl control  
Health comments:  
     
 

Typical day for dog

  
  Please list what the dog is doing and with whom during the following times:  
5:00am  
6:00am  
7:00am  
8:00am  
9:00am  
10:00am  
11:00am  
12:00 noon  
1:00pm  
2:00pm  
3:00pm  
4:00pm  
5:00pm  
6:00pm  
7:00pm  
8:00pm  
9:00pm  
10:00pm  
11:00pm  
12:00 midnight  
1:00 to 4am  

How many hours (maximum) can this OES stay alone?

How does dog behave when alone?

Is dog confined or allowed run of the house when alone?

Has dog been crate trained?
Please answer one below:                
When left alone inside, is dog:

loose?

confined to one room?

crated?

In basement?
                 
Temperament

 
Please answer all that best describe the dog:  

aggressive

confident

dominate

excitable

hardheaded

laid-back

nervous

responsive

sedate

shy

stubborn

submissive

timid

hyper

puppyish
                   
 

Characteristics and Peculiarities
 
The following is a list of dog behavior problems. Please list either (always - sometimes - never). If always or sometimes, please describe (when, where, why, etc.)
Barking excessively - under what condition?  
Begging  
Biting - under what circumstances?  
Growling - when  
Showing teeth - when  
Car behavior when riding  
Car chasing  
Car sickness  
Chewing - destructive  
Dog fighting  
Excessive wetting  
Food guarding  
Garbage ransacking  
Grooming self  
Herding  
Housebreaking "mistakes"  
Jealousy  
How is dog with children, and can dog be trusted with infants and small children?  
Protective?  
How does dog react with strangers, other dogs and animals?  
Jumping fences  
Jumping furniture  
Jumping on people  
Leash rejection  
Pulling on leash  
Mounting  
Nipping and mouthing  
Fear of confinement  
Fear noises  
Fear people  
Running away  
Stealing food  
Separation anxiety  
Unique#1  
Unique#2  
Unique#3  
     
 
How soon must you, or how desperate are you to give up the dog?  Would you be willing to keep the dog until it is placed?

Comment:

  
  Before this dog can be placed in a new home, he or she must be groomed, updated on inoculations and have a current heartworm test. We also recommend that the dog be altered. If the owner is unable to do these things, we ask for a donation to help cover these expenses. We realize that every situation is different and our main concern is the welfare of the dog. Thank you for your cooperation.  I, (owner of said dog), have read, understood, and answered all of the above questions completely and honestly, making no misrepresentations concerning the temperament, health or behavior of the above named dog.  
     

Date

  

Digitally signed

  
 

(owner)

  
     

Digitally signed

  
 

(witness) 

  
     


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After submitting you will be asked to enter a code for security reasons. Then you will be returned to the  TxOESR, Inc. home page.
You will also receive an email acknowledging
your questionnaire submittal.