Annual Client Questionnaire Answer the following questions as they relate to you, your child (for autism dogs), or your population (for facility dogs).Handler's Name* First Last Recipient’s First and Last Name, if different from handler. First Last Name and relationship to handler of the person completing this form, if different from hander.* Dog's Name* Email* Phone*Physical Address, if changed since last annual questionnaire Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country 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 Is your dog still in active service?* Yes No If yes, please list at least three Custom Assistive Tasks (Cues) your dog performs to mitigate the symptoms of your disability. If no, please explain why your dog is not in active service.*Dog Equipment: Please list the type of COLLAR and LEASH your dog is using and describe any OTHER equipment used.*Do you abide by your local dog leash laws when in public?* Yes No Has your dog received a wellness exam by your Veterinarian in the last 12 months?* Yes No Do you have veterinary insurance (not required)?* Yes No What kind of food is your dog currently eating?* What is your dog’s current weight?* Is your dog's license current?* Yes No How do you ensure you have your service dog badge/ID card with you in public?*Does your dog have any medical problems that would affect his/her ability to be working as a service dog?* Yes No If yes, please explain.*Is your dog working to your expectations?* Yes No If no, please explain.*Please describe a typical day for you with your dog.*Please describe a typical week for you with your dog.*What are 3-5 of the most common places your dog works?*List the Custom Assistive Tasks that your dog does to mitigate the symptoms of your disability in public (for facility dogs, in your facility).*Have there been any significant changes in your lifestyle or home environment in the past year?* Yes No If yes, please explain.*How do you feel your dog’s Assistive Tasks are mitigating the symptoms of your disability and/or increasing independence?*Is there something you would like your dog to do for you that it does not currently do or any changes in your symptoms or needs that we should be aware of?* Yes No If yes, please explain.*If you work, have there been any changes in your employer, role at work, or work environment in the past year?* Yes No If yes, please explain.*For each category, indicate whether or not you regularly utilize these cues with your service dog and whether your dog is PROFICIENT or NOT PROFICIENT at these cues. Proficiency means the dog responds to the cue with the correct behavior at least 90% of the time.Balance Cues (e.g. Brace, etc.) Used Regularly Not Used Regularly Balance Cues (e.g. Brace, etc.) Proficient Not Proficient Retrieval Cues (e.g. Get It, Bring, etc.) Used Regularly Not Used Regularly Retrieval Cues (e.g. Get It, Bring, etc.) Proficient Not Proficient Search Cues (e.g. Get Help, Find Person, etc.) Used Regularly Not Used Regularly Search Cues (e.g. Get Help, Find Person, etc.) Proficient Not Proficient Positional Cues (e.g. Heel, Side, Follow, etc.) Used Regularly Not Used Regularly Positional Cues (e.g. Heel, Side, Follow, etc.) Proficient Not Proficient Social Cues (e.g. Visit, Wave, Bow, etc.) Used Regularly Not Used Regularly Social Cues (e.g. Visit, Wave, Bow, etc.) Proficient Not Proficient Deep Pressure or Grounding Cues (e.g. Squish, Lap, Focus, Chin, etc.) Used Regularly Not Used Regularly Deep Pressure or Grounding Cues (e.g. Squish, Lap, Focus, Chin, etc.) Proficient Not Proficient Interruption Cues (Focus, Nudge, respond to triggers, etc.) Used Regularly Not Used Regularly Interruption Cues (Focus, Nudge, respond to triggers, etc.) Proficient Not Proficient Other Cue: Other: Used Regularly Not Used Regularly Other: Proficient Not Proficient Are there any new or unexpected assistance behaviors that your dog has learned in the last year?* Yes No If yes, please describe.Please indicate if your dog has exhibited any of the following behaviors:* Bitten a person Bitten a dog Knocked someone down Pulled you out of your wheelchair or off your feet Growled at dogs Growled at people Excessively barked at people, dogs, or something in the environment None of these Have any insurance claims or reports to the police been filed in regard to an incident involving your dog?* Yes No If yes, please describe.Does your dog demonstrate any adverse body language or have difficulty during any of the following?* Being dressed or groomed Traveling (entering and exiting buildings, riding in car, plane, train,etc.) Being in crowded, noisy environments Being around other dogs Being around children Other None of these If any of the above are checked, please describe the issue you are noticing as thoroughly as you can.What does your dog do when they see food on the ground in public or when you or someone else is eating?*Are there any updates to your emergency contacts or your Service Dog Contingency Plan?* Yes No If yes, please describe changes below.Do you expect your service dog to retire in the next 24 months?* Yes No Maybe If yes, would you like to discuss the possibility of applying for a successor dog? Yes No Please share any additional information about your dog or your accomplishments as a service dog team in the last year.AUTISM SERVICE DOGS ONLY – If you have an autism service dog who performs handle-led walking with your child, can the dog lie down or auto-settle without the child letting go of the handle? Yes No SERVICE DOGS ONLY – List the Assistive Tasks that your dog does for you at home.SERVICE DOGS ONLY – Have there been any changes in your key care providers since placement (primary care doctor, mental health provider, ABA therapist, or other key specialists) or changes in your care routines? Yes No If yes, please provide the updated names and contact information.FACILITY DOGS ONLY – Average number of clients (individuals served by your facility) that your dog interacts with on a monthly basis. FACILITY DOGS ONLY – Has anything changed about the work your dog is doing or the populations you are serving? Yes No If yes, please explain.
