SAMPLE  QUESTIONNAIRE
(This questionnaire can be used to screen staff and residents prior to initiation of 
an animal-assisted therapy program.)

    NAME: _____________________________  STAFF POSITION: ____________________________
                   (Optional)                                        Optional)
    1.        What is your opinion of the proposed plan to have pets visit the 
	facility (i.e. nursing home,mental health center, etc.) 
	for residents to interact with? (Please check one)
            _____a.. strongly approve
            _____b.  approve
            _____c.  neither approve nor disapprove
            _____d.  disapprove
            _____e.  strongly disapprove
            _____f.  no opinion
    2.       Have you ever had a pet or pets?
            _____a . No, I have never had a pet?
            _____b. Yes, I have had a pet.  What kind(s) have you had? ___________
            			____________________________________________________
    3.       Do you have allergies to cats, dogs or other animals?
            _____a.  No,I have no allergies to either cats or dogs as far as I know.
            _____b.  Yes,I am allergic to cats.
            _____c.  Yes,I am allergic to dogs.
            _____d.  Yes,I am allergic to both cats and dogs.
            _____e.  Yes,I am allergic to the following animals: 
                     (other than cats and dogs)_____________________________________
    4.       Do you dislike any particular type of pet animals?
            _____a.  No, I like all animals.
            _____b.  Yes, I dislike cats.
            _____c.  Yes, I dislike dogs.
            _____d.  I dislike both cats and dogs.
            _____e.  I dislike the following animals (other than cats and dogs).
    5.   What problems, if any, do you think might arise if pets were allowed to 
	visit on a regular basis?
         ____________________________________________________________________
         ____________________________________________________________________
         ____________________________________________________________________
    6.  Are there areas in the facility where you believe pets should not be allowed 
	(Pets are automatically excluded from any area where food is being served)?
         ____________________________________________________________________
         _____________________________________________________________________
    7.  What benefits, if any, do you think there might be if pets were allowed to 
		visit on a regular basis?
         ____________________________________________________________________
         ____________________________________________________________________
         ____________________________________________________________________
    8.  Would you be willing to participate in a pet visitation program on a regular 
	basis?
            _____a.  Yes, I would be willing to participate.
            _____b.  No, I would not be willing to participate.
    9.  If you have any comments, suggestions, or questions that aren't addressed 
	elsewhere in the questionnaire, please feel free to write them in here.
           _____________________________________________________________________
           _____________________________________________________________________
           _____________________________________________________________________
           _____________________________________________________________________
           _____________________________________________________________________
           _____________________________________________________________________
Please return this questionnaire to:

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