SHIBA INU RESCUE SERVICE
- Home Evaluation -
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Date:___________________
This questionnaire is prepared for your benefit, the prospective owner, and the Shiba Inu that you
plan to have become a part of your family. Please answer the following questions and return this
form at your earliest convenience so that you can be placed on a waiting list for a rescued dog.
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Name:______________________________________________________________________
Address:___________________________________________________________________
City:___________________________________State & Zip:______________________
Phone:__________________________________Occupations:_______________________
___________________________________
1. Why do you want a Shiba?_____________________________________
___________________________________________________________________________
___________________________________________________________________________
2. Have you ever owned a Shiba before?_______When?______________
Where did you get it?_______________________________________________
3. What happened to him/her?_____________________________________________
4. Who is this Shiba for? Self?______For Whom?_______________________
5. If single, your age______ Live Alone?______ With Family?______________
6. If married, do you both work?_____Husbands/Wife's Hours_______________
7. How many children at home?________Ages:_______________________________
8. Who will be responsible for the Shiba?_____________________________
9. Do you rent?____Own a Home?____Apartment?____Are you moving?_________
10. Does your lease allow pets?____If moving, when_______Where____________
11. Do you have a 6-ft fenced yard?_________Acreage?_______How Much?_______
12. Is the dog to be fenced in or let loose?______________________________
13. Do you intend to keep the dog primarily indoors or out? Please elaborate
______________________________________________________________________
___________________________________________________________________________
14. Do you have a fence?______Type?___________________Height?_____________
Is the fence secure and solid?____What types of gates?________________
Can children open the gates?__________________________________________
15. What types of improvements are needed to provide a secure yard?_______
___________________________________________________________________________
16. Are you willing to make the improvements?______When and how long will it take?
____________________________________________________________________
17. If you have a pool, is it fenced?______If you have a dog run is it secure?_______
18. Have you checked the yard for dangerous articles, plants, or anything the dog could use to
climb the fence?_______________________________________
19. Are you aware of any distractions outside your yard that could plague the dog? (Such as
neighbor's dog, loose dogs on street, mischievous children)__________________
20. Can strangers gain access to your yard from the streets?______________
21. Any allergies to pets?________________________________________________
22. Do you have other pets?_____What kind and sex?________________________
23. Where did you get your pet?___________________________________________
How long have you had him/her?________________________________________
24. If you don't have a pet now, have you had a pet before?_______________
What kind and sex?_____________How long did you have him/her?_________
What happened to him/her?_____________________________________________
25. If you have other animals, what have been your main problem with them?
___________________________________________________________________________
26. If you have other dogs, would you consider them aggressive or submissive to other
people?_____________to other animals?__________________
27. If you have birds, rabbits, cats, etc., are you prepared to spend the time necessary to
accustom them and the dog to each other? _______. Can you isolate the dog from the other
animals if they cannot get along?_________________
28. Are you willing to take time with the acquisition of a Shiba, read and learn all the facts of
temperament, socialization, grooming and proper handling and understand the time required to of
the breed?____________________________
29. Have you discussed with your family the pros and cons of owning a Shiba?___________
30. Have you asked yourself whether your lifestyle is so busy that you might not have the time or
energy to properly care for a dog?________
31. Is your lifestyle such that friends, relatives and children gain admittance to your home,
property, and car without your supervision?_______
32. If you have children, are you willing to accept the additional responsibility of a
Shiba?______________Have you taught your children the proper way to treat a living
animal?________________
33. Does everyone in your family want a dog?______________________________
34. What other breeds have you been contemplating?________________________
___________________________________________________________________________
35. What is your family's overall reaction to owning a dog?_______________
___________________________________________________________________________
36. Which members are enthusiastic? Unenthusiastic?_______________________
___________________________________________________________________________
37. What concerns have been voiced by other family members?______________
___________________________________________________________________________
38. Do you realize that a Shiba may live for 10-18 years and are you committed to care for it that
long? _____________
39. A Shiba enjoys a daily walk, and, if properly conditioned, can go hiking or jogging with you.
Have you and your family carefully considered how the dog would fit into your
lifestyle?________
40. If you expect to get a young dog, do you understand that early socialization is the key to
developing a well-balanced adult Shiba? ___________, do you realize that socialization means
taking your dog into crowded areas outside of your home and having strangers pet the dog?
_________________, that this period starts at about four months of age? _____________. Are
you willing to spend this kind of time? _________________
41. Are you likely to enroll your dog in obedience training?______________
42. Are you willing to attend obedience classes to train the dog?_________
Which family members would be expected to assist with home training?________
___________________________________________________________________________
43. What kind of work or behaviors do you expect of this dog?_____________
___________________________________________________________________________
___________________________________________________________________________
44. Name the most recent dog-training books you have read.
___________________________________________________________________________
___________________________________________________________________________
45. What amount of time and effort do you want to devote to training
him/her?____________________________________________________________________
46. What is your definition of disciplining a dog?________________________
__________________________________________What is your initial reaction to the idea of
disciplining your dog?_________________________________________
47 What are your training objectives? __________________________________
48. Do you have a sex preference?________Which?___________________________
49. Would you consider the opposite sex?__________________________________
50. Would you be interested in an older dog?______________________________
51. Would you be interested in a rescued dog?_____________________________
52. Would you be interested in a young adult/older puppy?_________________
53. Are you agreeable to returning the dog, should some unforeseen circumstance arise wherin
you would no longer be able to keep the dog?_____
54. Would you be willing to allow us to visit your home?__________________
55. How did you find out about us?________________________________________
56. Your comments and suggestions:________________________________________
____________________________________________________________________________
____________________________________________________________________________
57. Color, sex and age preference in a Shiba:________________________________
58. Please list TWO character references whom we may contact and their telephone #:
________________________________ _______________________________________
________________________________ _______________________________________
Your Signature:_____________________________________Date:__________________
Thank you for your cooperation. This comprehensive questionnaire helps us in placing
the right
dog with the right family. An improper placement, or one in which all the details aren't known can
end tragically, usually for the dog. Again thank you.
Shiba Rescue Service
(Address and phone number or rescue organization )
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