===== PAGE 1 ===== # KENTUCKY STATE UNIVERSITY SERVICE AND EMOTIONAL SUPPORT ANIMAL POLICY DATE

| For those who qualify to have a service animal on campus: |
| ● The student must have a disability as defined by the ADA |
| ● The accompanying animal must be trained to do specific tasks for the qualified individual |
| ● If a service animal will be kept on campus, students are asked to register with the ADRC so that accommodations can be made |
| Student Information | |||
| Full Name: | |||
| CWID: | |||
| Date: | |||
| Present Academic Status: (Circle One) | |||
| First Year | Second Year | Third Year | Other |
| Animal Name: | |||
| Animal Type: | |||
| Male or Female: | |||
| Breed Description, Age, Weight, etc.: | |||
| To be completed by the provider: |
| What are the students medical or mental health diagnosis? |
| Date diagnosed: |
| Describe in detail to what extent and with what frequency the student is impacted by disability symptoms: |
| Does the student require on-going treatment? |
| Describe in detail how the student's mental health impairment has affected their functioning (that is, how is the student substantially limited)? Note: Federal law defines a person with a disability as someone who has a physical or mental impairment that substantially limits one or more major life activities. That suggests that a diagnosis (label) does not necessarily equate with a disability (substantial limitation). |
| When was your last interaction with the student about this mental health diagnosis, and how frequently do you meet? |
| What therapeutic procedures are being used for treatment purposes? |
| What specific symptoms will be reduced by having an ESA, and how will those symptoms be mitigated by the presence of the ESA? General evaluations are not enough. “The animal alleviates anxiety,” for example, is overly generic and fails to clarify how the animal can lessen the symptoms of this student's impairment. |
| In your opinion, how important is it for the student's well-being that an ESA be in residence on campus? |
| Have you discussed the responsibilities that come with taking good care of an animal while participating in regular college activities and living on campus? Do you believe those responsibilities might intensify the student's symptoms in any way? Please note that students are not permitted to bring in an animal prior to approval. |
| Name & Credentials: |
| Address: |
| Telephone: |
| Email: |
| License #: |
| Professional Signature: |
| Date: |
| I, ,hereby authorize the release of the following information as well as any pertinent documentation to the Accessibility & Disability Resource Center at Kentucky State University for the purpose of determining my eligibility for accommodations. |
| CWID: |
| Student’s Signature: |