Enrollment Questionnaire for Clinics and Shelter

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Project Name: Canine Leptospirosis Surveillance in Puerto Rico, 2016 – 2017
This form will provide project coordinators with background information on your facility. Please provide the information as accurately and completely as possible. 
GENERAL INFORMATION
Name of Facility: ____________________________________________            Type of Facility:  ☐ Clinic   ☐ Shelter
Street Address: ______________________________________________________________________________________
       City: __________________________  Municipality: _____________________________ Zip: _____________________
Point of Contact Name:  ________________________________________ Job Title: _______________________________
       Phone Number: _______________________________  Email Address: ______________________________________
Does your facility have a computer that can be used to record patient test results?:      ☐ Yes     ☐ No
If a computer is available, what software is available? Check all that apply.
        ☐ Microsoft Word         ☐ Microsoft Excel          ☐ Microsoft Access       ☐ Microsoft PowerPoint           
Does your facility have a fax machine?      ☐ Yes     ☐ No
Does your facility have internet access?    ☐ Yes     ☐ No
Do you vaccinate dogs for leptospirosis?  ☐ Yes, name of vaccine(s): ____________________________________  ☐ No                   
For clinics, approximately how many dogs does your clinic see?    _____________   per   ☐ week   ☐ month
How many dogs with febrile illness of unknown cause does your facility see?  ____________  per    ☐ week ☐ month 
How many dogs diagnosed as or suspected to have leptospirosis does your facility see? _________ per ☐ week ☐month 
QUESTIONS FOR SHELTERS ONLY
Size and Activity Level:
Shelter capacity (# of dogs it can house): _________________ Average # of new dogs each week: __________________
How often is the shelter full?       ☐ Most of the time      ☐ Sometimes      ☐ Rarely       ☐ Never
Origin of dogs (provide percentage where appropriate)
Are dogs:   ☐ Surrendered by owner:  ____ %                ☐ Transferred from other facilities:  ____ %      
         ☐ Picked up in the community:  ____ %       ☐ Other, specify ____________________,  ____  %       
From which communities do most dogs originate? If possible, specify name of area and an approximate percentage. 
    1) ____________________________________________________________         ______ % 
    2) ____________________________________________________________         ______  %
    3) ____________________________________________________________         ______ %
What is the most remote distance and community from which you receive animals? ______________________________
Veterinary Care:
Is veterinary care provided by:   ☐ a full-time onsite vet        ☐ a part-time onsite vet, how often/week? _____________
                                                          ☐ a separate veterinary clinic
If a separate veterinary clinic provides care: 
       Clinic Name: _______________________________________________   Phone No: __________________________
       Street Address: ________________________________________ City: _____________________  Zip: ___________
In what capacity does the veterinarian work with your shelter? Check all that apply.
☐ Euthanasia   ☐ Consultation   ☐ Spay/neuter   ☐ Treatment of sick/injured   ☐ Preventive (vaccination, deworming)
Send this form back to the Puerto Rico Health Department by fax to 787-751-6937 or by email to [email protected]. Thank you!