Home Visit – Foster and Adopter Applicants Tibetan Spaniel Rescue Home Visit Checklist This form is used to conduct and document visits to homes of prospective adopters or fosterers. The Home Visit Checklist comes in two versions - the online version below and a printable version (pdf) accessed from the Resources for Coordinators page. The online version will be the official version that will be stored permanently with the applicant's Prospective Adopter Questionnaire or with the volunteer fosterer's Volunteer Application and Foster Home Questionnaire on Drive. If you are doing a virtual visit (via videochat) and you have two screens - one to view the home and the other to view the form (e.g., a laptop and a smartphone) - you can complete the online version while you are conductiing the visit. This is ideal since the built-in logic of the online form will ensure that you don't miss anything. However, if that's not possible, you can use the printable version while you are conducting the visit and then complete the online version after the fact. The printable version is designed for taking notes by hand while you are conducting a visit. It follows the same order as the online form. Bear in mind that you may not always be able to conduct the visit in the same order as the form; you may need to jump around on the form. This may be easier on the printable version than the online version. Before beginning the home visit, it is best practice to look up the home on realty sites and view any photos there. You may be able to find basic facts such as square footage and year built and get an idea of the general layout and appearance. Knowing this kind of info will facilitate the visit. You can pre-fill this info on the form before starting the visit (but do not submit the form). When you must stop before completing the Checklist, scroll to the end where you will find a Save and Continue button. When you press the Save and Continue button, you will receive a link so that you can return to your Checklist later. You can also opt to have the link sent to you by email. When you have finished answering all the questions, press the Submit button. If you missed a required question(s), you'll receive an error message. Scroll down through the form to find the errors in red. After correcting the errors, you must re-submit the form. If you made no errors, you'll see a confirmation message.General InformationRegion:(Required) Northeast Mid-Atlantic-Midwest Southeast Gulf South North Central Northwest Southwest Evaluator Name(s):(Required)This is the name of the Coordinator or volunteer doing the visit and completing the form. Type of Visit:(Required) Adoptive Home Foster-to Adopt Foster Is this visit related to a specific Tibbie available for adoption?(Required) Yes No specific Tibbie - foster volunteer visit Tibbie's Name:(Required) Applicant Name(s):(Required)The "applicant" is the prospective adopter or fosterer whose home you are visiting. Applicant Cell Phone:Applicant Email:(Required) Visit Date:(Required) Month Day Year Time:(Required) Hours : Minutes AM PM AM/PM Mode of Visit:(Required) Videochat In Person HomeThese questions are about the home you are visiting.Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Type of Dwelling:(Required) Single-Family Townhouse/Row House Apartment/Condo Size of Dwelling:(Required) Large (>2000 sq ft) Medium (1000-2000 sq ft) Small (<1000 sq ft) Setting (check all that apply):(Required) Rural/Semi-Rural Suburban Urban/Semi-Urban Wooded Open Acreage Waterfront On Highway On Country Road On Neighborhood Street Busy Street Quiet Street Borders Park/Open Sapce How far is the nearest emergency veterinary clinic?(Required) Family and PetsWe generally begin the visit by meeting the family members and pets present.Please list the names and ages of all persons who live in this home:(Required)This should sync with the Questionnaire the applicant completed.Did you meet all of the family members?(Required) Yes, I met all the family members. No, one or more family members were not present. Which member(s) was not present? Why?(Required)Who will be the Tibbie's main caregiver?(Required) Does anyone have dog allergies?(Required) Yes No Are children present?(Required) Yes No Describe the children's behavior:You may ask questions to elicit how they feel about a Tibbie coming to live with them.Do pets live in the home?(Required) Yes No List and describe the pets you met:(Required)Include type (dog, cat, etc.), breed (dog), age, sex. This list should sync with the list on the Questionnaire.Were there any pets you did not meet?(Required) Yes, one or more pets were not present. No, I met them all. Which pets did you not meet? Why?(Required)Did all the pets you met appear to be well cared for, clean and healthy?(Required) Yes No Did all the pets appear to be well socialized and friendly?(Required) Yes No Do you have any concerns about the pets' well-being?(Required)Examples of concerns are "cage not clean," "reactive dog," "scratching-possible fleas." Yes No Explain your concerns about the pets:(Required)How do the family members and pets interact?(Required)Interior of HomeYou may need to skip around a bit in this section. After meeting the family and pets, we generally ask to begin by viewing the exterior doors to check for double barriers. However, while walking around, note other features such as staircases, types of flooring, where the dog eats and sleeps, and hazards. Describe all exterior doors and type of barrier, if any:(Required)Examples: Front door has a storm/security door, front door leads to a screened porch, slider leads to fenced yard, baby gate blocks access to front door.Do all doors leading outside have a double barrier?(Required) Yes No Are there staircases?(Required) Yes No Describe all staircases:(Required)Examples: Wooden treads with carpet runner, open with no risers, anti-slip strips on each treadIs there a basement?(Required) Yes No Would the Tibbie have access to basement?(Required) Yes No Condition of the basement:(Required) Is there a garage?(Required) Yes No Would the Tibbie have access to garage?(Required) Yes No Condition of the garage:(Required) What types of flooring are there?(Required)Examples: hardwood, vinyl, tile, carpet, throw rugs Where would the Tibbie eat?(Required)Describe the location and whether it is clean. Where would the Tibbie sleep?(Required)Describe the location and whether it is clean. Would the Tibbie be allowed on furniture?(Required) Yes No Would the Tibbie have free run of the house?(Required) Yes No Where would the Tibbie typically spend the day?(Required)Examples: gated into family room, free run of house When the family is away from home, where would the Tibbie stay?(Required)Examples: family room, crate in kitchen, laundry room, pen in basement, outdoor run Is there a dog door?(Required) Yes No Where does the dog door exit to?(Required)Examples: from kitchen to gated deck, from mud room to fenced back yard, from garage to dog run Can the dog door be closed?(Required) Yes No Describe when the dog door is open and when closed:(Required)If the door cannot be closed, enter N/A. Are there any houseplants?(Required) Yes No Describe type and location of plants:(Required) Did you observe any of the following potential hazards at "Tibbie level":(Required)Remember that Tibbies climb. Check all that apply. Hanging electrical wires or cables Small objects/choking hazards Chemicals such as cleaning supplies Human edibles such as candy Trash Other None of the Above Describe the hazard(s):(Required)If it were necessary to quarantine the Tibbie for two weeks, where and how would the dog be kept separate?(Required)If there are no other dogs, enter N/A.Overall Impression of Interior:(Required)Check all that apply. Immaculate Well-kept "Lived In"/Clean Messy Trashed/Dirty Poorly Maintained Exterior of HomeWhen we have finished looking around inside, we generally go into the backyard or other area where the dog would potty and/or exercise. Does a yard adjoin the home?(Required)If there is no fenced back or front yard, we need to view where the dog would exercise and potty. The home has a front yard and/or back yard. The home has no yard but there is an off-street common area for use of the residents. None of the above. Describe the common area:(Required) Since the home has neither a yard nor common area, describe where the dog would potty and exercise:(Required) Is there a fenced area in which the Tibbie can go potty or exercise?(Required)If the only fence is an electronic fence, check "No." Yes No Roughly, how big is the fenced area?(Required)Examples: 10'x20', 1/4 acre Describe the fenced area:(Required)Examples: grassy with some landscaping shrubs and a tree, sandy lot with no shade except under deck, pea gravel with some potted palms Fence Standard Inspect the entire fence-line with attention to each of these features: The fence should be at least 4 feet high and have no gaps greater than 3” under the fencing, adjacent to gate posts or where the fence meets the house walls There should be no gaps around gates and gates should latch securely, preferably with a lock. Chain link should be “tight,” not sagging. Pickets should be spaced no more than 3.75” - 4” apart, depending on size of Tibbie. Describe the type of fence:(Required)Include type of material (such as wood plank, chain link, vinyl picket), height, spacing between any pickets. Do the gates latch securely?(Required) Yes No Are there locks on the gates?(Required) Yes No Walk the entire fenceline to inspect for escape points. Are there any gaps, holes or other defects that would allow a Tibbie to dig under, climb over or squeeze through the fence?(Required) Yes No Describe the fence defects in detail:(Required)These defects must be remedied before we can transfer the Tibbie into the applicant's care. Be specific.Since there is no fenced area, describe where the Tibbie would potty and exercise:(Required)Is anything pushed up against a fence or a rail which would allow the Tibbie to climb up and over the fence or rail?(Required)Examples: outdoor furniture, garden equipment Yes No Describe the climb/fall hazard:(Required) Are there any water features within the area the Tibbie could access?(Required) Pool Pond Other None Since you checked Other, describe the feature:(Required) Is there any barrier to the feature?(Required)Examples: pool fence, gate on deck Are any predatory, poisonous or otherwise dangerous animals known to be in the area?(Required)Examples: coyotes, birds of prey, venomous snakes, cane toads, dangerous stray dogs. Yes No List dangerous animals in the area:(Required) What measures would the applicant take to protect the Tibbie against dangerous animals?(Required)Are any toxic landscaping plants accessible to the dog?(Required)Examples: Sago palm, lily of the valley, rhododendron Yes No Don't Know - recommend survey using toxic plant guide Describe the plants:(Required) Did you observe any of the following potential hazards in a location where the Tibbie could access them?(Required)Remember that Tibbies climb. Check all that apply. Hanging electrical wires or cables Small objects/choking hazards Chemicals such as pool supplies, automotive fluids High places to leap from such as a deck or porch Human edibles such as candy Trash Other None of the Above Describe the hazard(s):(Required)Overall Impression of Exterior:(Required)This pertains to whatever kind of exterior area the Tibbie would have access to, whether it's a fenced yard or other type of outside area. Check all that apply. Immaculate Well-kept Messy Trashed/Dirty Poorly Maintained Summary and EvaluationThe purpose of this section is to summarize your observations and document modifications and/or counseling needed.Did you identify any interior hazards or escape routes?(Required)Refer back to the Interior section. Yes No Did you identify any exterior hazards or escape routes?(Required)Refer back to the Exterior section. Yes No Check all interior hazards that you have identified:(Required)The Coordinator must discuss these concerns with the applicant. Absence of double barrier to exterior door Slippery staircase or flooring Toxic houseplants Dog door that doesn't close Hanging electrical wires or cables Small objects/choking hazards Chemicals such as cleaning supplies Human edibles such as candy Trash Other None of the above Check all exterior hazards that you have identified:(Required)The Coordinator must discuss these concerns with the applicant. Fence defects Insecure gates Toxic landscaping Water feature Predatory/venomous/dangerous animals Hanging electrical wires or cables Small objects/choking hazards Chemicals such as pool supplies, automotive fluids High places to leap from such as decks or porches Human edibles such as candy Garbage Other None of the above Does the home need modification?(Required) Yes No Does the applicant need counseling about dog care?(Required) Yes No List each modification (both interior and exterior) discussed:(Required)Later on, we will use this list to verify that the modifications have been completed. Please be specific enough that someone other than yourself could do the verification.List each topic on which the applicant was given or needs counseling:(Required)Please be specific. Overall, would the home environment - inside and outside - be Tibbie friendly once any modifications above are done?(Required) Yes No Do you think the applicant will love and care for a Tibbie properly?(Required) Yes No Would you feel comfortable placing a Tibbie here?(Required) Yes No Use this space for any other comments about this home visit:
