NEW ENGLAND OLD ENGLISH SHEEPDOG RESCUE, INC.
QUESTIONS FOR SOMEONE GIVING UP A DOG

If you need to surrender your pet be advised that though we do not have an age limit – we generally do not accept animals that are aggressive or have a bite history.

Date:_______________ Dog's name ________________________________ Age________

Present owner________________________________________________________

Address_______________________________________Email________________________

Home 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 ______ Altered ______Tail _______  AKC records______________

Coat length (puppy cut, full length, shaved?)_________Last groomed? (date)_______

Groomer's name, address, phone___________________________________________________

Does dog need to be groomed now?______ matted_______ bath________

How does dog react to being groomed? ___________________________________

Food type_________________________________________________________

Feeding schedule____________________________________________________

Housebroken? _____  If yes, how long can dog left?__________________________

What signal does dog give?____________________________________________

Is dog on lead or left alone for "potty"?____________________________________

Any information about the previous owner will be appreciated in the space below.

Previous owner's name______________________________________________________

Address____________________________________ Email___________________________

Phone (home)_____________________ (work)_____________________________

Children_____ how many ____________ ages______________________________

Other animals_____ how many__________ types ____________________________

Reason for giving up____________________________________________________________

Veterinarian ________________________________________________________

Address____________________________________________________________

Telephone __________________________________________________________

Commands dog responds to:

Please answer either (always - sometimes - never)

Sit___________ Down__________ Stay__________ Come__________ Heel______

Others______________________________________________________________

Is dog leash trained? ______if yes (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' name__________________________________________________

Address,phone________________________________________________________

Rabies ______________________ Tag #_________________ date______________

Distemper__________________________________________ date______________

Hepatitis___________________________________________ date______________

Parainfluenza _______________________________________ date______________

Parvovirus __________________________________________ date______________

Leptospirosis________________________________________ date______________

Bordetella__________________________________________ date______________

Corona____________________________________________ date______________

Fecal______________________________________________ date______________

Heartworm - date tested_______ last given ___________ type used________________

Weight__________ Please describe general health - including history of arthritis, colitis, skin problems, allergies, etc. Also, urine & bowel control:_____________________________

Typical day for the 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_____________________________________________________________

12:00midnight________________________________________________________

1:00 to 4 am__________________________________________________________

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 circle one below.
When left alone inside, is dog:    loose?    confined to one room?    crated?   in basement?

Temperament

Please check all that best describe the dog:

aggressive_____ confident_____ dominate______ excitable______ hardheaded_____

laid-back______ nervous______ responsive______ sedate______ shy______

stubborn______ submissive______ timid______ hyper______ puppyish______

cooperative______ frantic______

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 conditions?_____________________________

Begging__________________________________________________________

Biting - under what cicumstances?______________________________________

Growling________ when__________ Showing teeth ________ when___________

Car behavior when riding______________________________________________

Car chasing________________________________________________________

Car sickness_______________________________________________________

Cat chasing_________________________________________________________

Chewing - destructive__________________________________________________

Digging_____________________________________________________________

Dog fighting__________________________________________________________

Excessive wetting_____________________________________________________

Food guarding_______________________________________________________

Garbage ransacking___________________________________________________

Grooming___________________________________________________________

Herding____________________________________________________________

Housebreaking "mistakes"______________________________________________

Jealousy____________________________________________________________

How is dog with children, and can dog be trusted with infants and small children?______

____________________________________________________________________

Protective?__________ Of whom? ________________________________________

How does dog react with strangers, other dogs and animals? _____________________

___________________________________________________________________

Jumping fences_______________________________________________________

Jumping on furniture____________________________________________________

Jumping on people_____________________________________________________

Leash rejection_______________________________________________________

Pulling on leash_______________________________________________________

Mounting ____________________________________________________________<

Nipping and mouthing___________________________________________________

Fear of confinement____________________________________________________

Fear of noises________________________________________________________

Fear of 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? ______________________________________________________

___________________________________________________________________

___________________________________________________________________


 
 

Before this dog can be placed in a new home, he 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_____________________

Signed______________________________________________________

(owner)

              ___________________________________________________

(witness)

Send completed form to:

NEOESR, Inc,  49 Stonehedge Road,  Lincoln, MA 01773
781-259-8173    placement@neoesr.org   Fax: 1-855-710-7395