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About

CCTR: HSC Report

Please complete the Home Safety Check form below.

Home Safety Check Report

CCTR HSC Report

Home Safety Check Report

"*" indicates required fields

Volunteer Information

Volunteer First Name*

Volunteer Last Name*

EMail Address*

Enter Email Confirm Email

Phone Number*

Street Address

Suite | Apt or Unit Number

City

State/Province

Zip / Postal Code

Country

Date of Home Safety Check*

MM slash DD slash YYYY

Did you read the Home Safety Check Procedures prior to your visit?*

Yes

No

Did you take the Home Safety Hazard Checklist to the visit to use as a guideline?*

Yes

No

Applicant Information

Applicant First Name*

Applicant Last Name*

Street Address*

Suite | Apt or Unit Number

City*

State/Province*

Zip / Postal Code*

Country*

Reason For Application*

Adopt A Dog From CCTR

Foster A Dog From CCTR

Foster And Adopt A Dog From CCTR

Household

Were All Family Members Present?*

Yes

No

Who Was Not Able To Attend Or Only Attend Briefly?*

Describe The Behavior Of Adults Among Themselves And To Any Other Pets Or Children.*

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?*

Yes

No

Describe The Behavior Of Any Children*

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?*

Such as the use of a respirator, wheel chair, crutches, hard of hearing, blind where CCTR should consider a dog with the capability to be a special needs dog

Yes

No

Please Explain Any Special Physical Needs*

Are All Members Of The Family Equally Excited About Getting A Rescue Dog?*

Yes

No

Please Explain*

Does The Applicant Appear To Be Willing And Financially Able To Care For The Dog In Later Years?*

Yes

No

If You Sense A Financial Concern On Their Part, Please Explain.*

Neighborhood

Describe The Applicant'S Street (Busy, Quiet, In-Between):*

Describe The Setting (Rural, Suburban, Urban):*

Are There Any Dogs Or Other Animals That Live Adjacent To This Property?*

Yes

No

List Type And Describe How They Are Contained:*

Did You See Any Stray Dogs Or Other Animals In The Immediate Neighborhood During Your Visit?*

Yes

No

Describe what was seen:*

Front Yard Fencing

Please Select The Type Of Front Yard That Is At The Home*

Describe The Fence (Height, Type, Condition)*

Is There A Lock On The Gates Of Any Of The Fences?*

Yes

No

Do You Feel The Fencing Is Able To Properly Contain A Cairn Terrier Without Repairs Or Restructure?*

Yes

No

Back Yard Fencing

Please Select The Type Of Back Yard That Is At The Home*

Describe The Fence (Height, Type, Condition)*

Is There A Lock On The Gates Of Any Of The Fences?*

Yes

No

Do You Feel The Fencing Is Able To Properly Contain A Cairn Terrier Without Repairs Or Restructure?*

Yes

No

Understanding Of CCTR Policies On Fences And Leashes

Did You Get The Impression That The Applicant Uses “Electric Fencing” Or Tie-Outs?*

Yes

No

Did You Get The Impression That The Applicant Fully Understands That Cairns Can Never Be Off Leash?*

Yes

No

Additional Home Information

Does The Applicant Have A Swimming Pool, Fishpond, Lake Or Other Body Of Water On Their Property?*

Yes

No

Please Describe Any Body Of Water On The Property*

Describe The Condition Of The Home (For Example, In Good Repair, Clean, Neat, Sloppy, Cluttered):*

Will The Dog Have Access To A Garage Or Basement?*

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?*

Yes

No

Please Describe By Type And List Any Safety Concerns A Dog May Face:*

Preparing For The Dog's Arrival

In Which Room Will A New Dog Sleep And What Will Be Used As Bedding:*

Is There A Crate Available?*

Yes

No

Describe The Size And Type:*

Did you make them aware that a crate is mandatory?*

Yes

No

Is There A Current Dog?*

Yes

No

In Which Room Does The Current Dog Sleep And What Is Used As Bedding?*

Where Is The Current Dog Kept When Home Alone?*

Describe The Current Condition Of The Dog (Clean And Groomed, In Need Of Grooming, Overweight, Friendly, Unsociable).*

Does The Applicant Have Other Pets (E.G. Cats, Rodents, Fish, Reptiles, Birds)?*

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?*

Are There Dog Toys Available?*

Yes

No

Describe Available Toys:*

Do You Feel They Plan On Getting Toys?*

Yes

No

Review Of The Hazard Checklist

Did You Notice Any Hazards?*

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:*

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?*

Other Comments

Gut 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?*

Yes

No

Please Explain*

(Remember, Even Great People Can Be Wrong For A Specific Breed Of Dog)

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?*

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