Service Animal Inquiry Form for Employees & Visitors
Service animals are defined as dogs that are individually trained to do work or perform tasks for people with disabilities. Examples of such work or tasks include guiding people who are blind, alerting people who are deaf, pulling a wheelchair, alerting and protecting a person who is having a seizure, reminding a person with mental illness to take prescribed medications, calming a person with Post Traumatic Stress Disorder (PTSD) during an anxiety attack, or performing other duties. Service animals are working animals, not pets. The work or task a dog has been trained to provide must be directly related to the person’s disability. Dogs and/or other animals (including but limited to birds, reptiles etc.) whose sole function is to provide comfort or emotional support do not qualify as service animals under the ADA. For more information see IRSC Board Policy 6Hx11-8.52 and Administrative Procedure AP-8.52 regarding Service Animals. Please return this completed form to the Human Resources Office.
Form Questions
- Is the dog a service animal required because of a disability?
- What work or task has the dog been trained to perform?
Service Animal Requirements
The service animal must be harnessed, leashed or tethered, unless these devices interfere with the service animal’s work or the individual’s disability prevents using these devices. In that case, the individual must maintain control of the animal through voice, signal, or other effective controls. (ADA)
I understand that as a safety precaution to the general population, my service animal should be kept clean, flea free, housebroken, and current with immunizations.
Emergency Contact Information
In case of an emergency, please give the name of the person who can take custody of the Service Animal, his/her relationship to you and phone number where he/she can be reached.
| Name of Person | Relationship to You | Phone Number |
|---|---|---|
Employee Information
