COVID-19 Home Visit Questionnaire

This form is for the adopter to fill out in the event that a physical home check is required. All answers must be truthful and honest. You may be asked to complete the form, and your answers will be reviewed by the adoption team. If you are self-isolating or have any concerns surrounding Covid-19, please inform a team member and we will be happy to discuss matters further.

Updated 22/06/2020

Adopters Name *

Phone Number (mobile/home) *

Adopters Address *

Dog Name (if known) *

Have you returned from any countries that have an outbreak of Coronavirus in the last 14 days?

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

Have you been in close contact with anyone who has traveled within the last 14 days to a country with a coronavirus outbreak?

Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?

Single Line Text

If the answer is “yes” to any of the questions, we will postpone the visit.

Digital Signature *

First

Last

I confirm the above information is accurate.

Comment

Current details on COVID-19 can be found on the World Health Organisation web site or from the Centers for Disease Control and Prevention web site.