This report is for the following placement:

Name of Facility

Name of Parent Company/Larger Organization

Facility Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Direct Supervisor's Name

Your Name

First Name

Last Name

Your Email

What is your title and how many patients do you serve in a day?

How many years have you worked in this position?

How many patients are served, on average, in the wing where the Bella's Buddies dog will be working?

In what medical department will the Bella's Buddies dog be working?

On average, how many patient interactions will the dog have every week?

Describe your vision in bringing a Bella's Buddies dog into your facility. In what ways will the dog support patients and staff?

ANNUAL REPORTING - FILL OUT THIS SECTION ONLY IF YOU HAD A BELLA'S BUDDIES DOG IN YOUR FACILITY FOR MORE THAN SIX MONTHS

DOG'S NAME

Microchip #

Does your dog's vest display the Bella's Patch each time he is in public?

Describe a situation in which the outcome would have been different had your dog not been present.

Did your Bella's Buddies dog volunteer at a community or school extra-curricular event during the school year? Please tell us about it.

Where did your Bella's Buddies dog spend most of the workday? In what ways did he support students and staff?

Did the secondary handler or other adults handle your Bella's Buddies dog this year? Please describe.

In the last year, did you gain any financial support to help with vet or food costs? Did you raise any funds for Bella's Buddies? Please explain.

Describe a situation, or more than one situation, in which you witnessed an exchange between your Bella's Buddies dog and a patient or staff member, and that exchange significantly altered the outcome of the situation.

HEALTH & VACCINE INFORMATION

DHPPC/DHPPLC Vaccine

YYYY

Rabies

YYYY

Most Recent Heartworm Treatment

YYYY

Heartworm Medication

Most Recent Flea/Tick Treatment

YYYY

Flea Tick Medication