Assistance Animal Verification Form

The ��AV is committed to supporting students with disabilities by allowing Assistance Animals (AAs) when an Assistance Animal is necessary for them to be able to use and enjoy their residential living space. The Assistance Animal Policy applies to all students and explains the specific steps necessary to request an assistance animal at UNA.

The American with Disabilities Act (ADA) defines a person with a disability as someone who has a physical or mental impairment that substantially limits one or more major life activities. The three factors influencing a determination of substantial limitation are 1) the nature and severity of the impairment, 2) the duration or expected duration of the impairment, and 3) whether the impairment is characterized as permanent or long-term. An Assistance Animal is defined as an animal that is necessary to afford the student with a disability an equal opportunity to use and enjoy UNA-owned housing, and provides emotional or other support that ameliorates one or more identified symptoms or effects of a person’s disability. Unlike service animals, support animals are not required to be trained to perform work or tasks.

A treating healthcare provider must complete and submit this Verification Form to Housing & Residence Life. The treating health care provider completing the form must specialize in a field consistent with the diagnosis, as well as be familiar with the student’s disability and the necessity for the requested Assistance Animal. To avoid any conflict of interest, documentation must be provided by a non-family healthcare provider. Documentation must also show that the requested AA is necessary for them to use and enjoy their residential living space; in addition, there must be an identifiable relationship, or nexus, between the requested AA and their disability. Please see the Assistance Animal Policy for additional information.

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Student First NameLegal Name

Middle NameLegal Name

Student Last NameLegal Name

Student Date of Birth

Name of Medical Provider

Medical Provider Address

Medical Provider Email Address

Medical Provider Telephone Number

Medical Provider License Number

As defined by the ADA, identify the disability for which the student is seeking an Assistance Animal.

How long have you treated this student for the diagnoses indicated above? Please indicate the date of the initial visit and number of visits since.

What is the nature and severity of this impairment?

What was the date and code of diagnosis for need of an Assistance Animal?

Does the student have a pre-existing relationship with this particular animal? If not, please explain why it is pertinent to treatment at this time.

How long is this impairment expected to last? Is it characterized as permanent or long term? Please explain.

How is this animal part of an ongoing treatment plan? Please explain in detail.

What identified symptoms or effects of the patient disability will be alleviated by this Assistance Animal

Describe how the requested Assistance Animal is necessary for the patient to use and enjoy their assigned university living space?

Verification

My submission below indicates that I am the treating professional and that all contents are accurate. I verify that I am not a relative or friend of the student.

Please make sure all required fields have been filled out correctly.

Your Assistance Animal Verification Form has been submitted. Thank you.

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