ADA Service Animal
“Service animal means any dog that is individually trained to do work or perform tasks for the benefit of an
individual with a disability, including a physical, sensory, psychiatric, intellectual or other mental disability. “
Companion Animals
A “companion animal” is a pet that is owned by an individual with a disability. A companion animal is NOT a
service animal and unlike service animals, companion animals will not need to accompany the individual with
the disability at all times.
Please answer the following questions as complete as you can. If the person with a disability has the
certification from the Service Animal Organization that trained the dog pleases attach and disregard the
questions.
1.Please provide specific evidence that the disability results in a functional limitation requiring an assistance
animal.
2.Please provide specific details on work and/or tasks performed by the assistance animal for the individual
with a disability.
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Signature of Diagnostician Completing Form Date
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Profession Phone #
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Professional License/Certification # State Issuing
