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Home My WebLink AboutOwner Surrender Evaluation Form Page 1 of 2 PART I: Who initiated this evaluation? (Please print name) Name: ______________________________________________ Date Initiated: ____________________ What are your concerns about the condition of this animal at the time of surrender? Be sure to describe your concerns in detail. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Intake form attached? Y N (If not, please attach) If impounded in field, are there field notes? Y N (If yes, please attach) Is there a veterinary exam report? Y N (If yes, please attach) Animal ID: ______________________ Date of Surrender: _____________________ PID: ___________________________ Activity#: _______________________ OWNER SURRENDER EVALUATION Page 2 of 2 PART II: Do you believe this person should not be allowed to adopt an animal from our shelter without consultation with staff about animal care? Indicate below and note the reason(s) why you think there has been mistreatment. Title Signature YES This person needs consultation NO This person does not need consultation Attending Veterinarian Notes: ____________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Title Signature YES This person needs consultation NO This person does not need consultation Animal Control Manager Notes: ____________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Title Signature YES This person needs consultation NO This person does not need consultation Assistant Director OR Veterinary Health Care Manager Notes: ____________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ PART III: Outcome: Allow adoption? Y N Add “Do Not Adopt” icon to PID and memo: Name: ________________________________ Date: ________________