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<br /> <br />Page 1 of 2 <br /> <br /> <br /> <br />PART I: <br />Who initiated this evaluation? (Please print name) <br />Name: ______________________________________________ <br /> <br />Date Initiated: ____________________ <br /> <br /> <br />What are your concerns about the condition of this animal at the time of surrender? <br />Be sure to describe your concerns in detail. <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br />__________________________________________________________________________________________________ <br /> <br />Intake form attached? Y N (If not, please attach) <br />If impounded in field, are there field notes? Y N (If yes, please attach) <br />Is there a veterinary exam report? Y N (If yes, please attach) <br /> <br /> <br />Animal ID: ______________________ <br />Date of <br />Surrender: _____________________ <br />PID: ___________________________ <br />Activity#: _______________________ <br />OWNER SURRENDER EVALUATION