Fillable Emotional Support Animal Request Form The Office of (Black Hills State University)

Fill Online, Printable, Fillable, Blank Emotional Support Animal Request Form The Office of (Black Hills State University) Form

Use Fill to complete blank online BLACK HILLS STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Emotional Support Animal Request Form The Office of (Black Hills State University)

On average this form takes 13 minutes to complete

The Emotional Support Animal Request Form The Office of (Black Hills State University) form is 4 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 48 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Black Hills State University

BROWSE BLACK HILLS STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Emotional Support Animal Request Form
The Office of Disabilities Services evaluates requests for Emotional Support Animals (ESA) in
Black Hills State University owned housing. Approval requires that a student must have an
impairment that rises to the level of a disability in that it substantially limits one or more major
life activities, and Reliable Third-Party documentation stating the presence of an ESA will have
therapeutic benefit in alleviating one or more of the identified effects of the disability.
We accept documentation from a Reliable Third-Party who has personal knowledge of the student
through a professional relationship involving the provision of disability related services and who
are practicing within their ethical, legal, and professional obligations. To consider requests for
ESAs, documentation provided should include the following specific components. The absence of
one or more of these components should not be considered an automatic reason to disqualify the
supporting documentation:
• Format – Reliable Third-Party documentation should be typed/printed on official
letterhead, dated, and signed from a licensed and qualified professional (e.g. psychologists,
neuropsychologists, psychiatrists, clinical social workers, licensed counselors, psychiatric
nurse practitioners, and other relevantly trained healthcare professionals). It is also
recommended that the Reliable Third-Party provide contact information and any
professional licensing information. The documentation should include the student’s name.
• Contact Dates - date when provider first met with the student regarding the condition and
date of the last professional interaction with the student regarding the disabling condition.
• Substantial Limitations – a statement that the student has a physical or mental
impairment that substantially limits one or more major life activities and describes the
nature of the impairment (that is, how the student is substantially limited).
• Type of Animal – the type of animal that is requested and that it is necessary in university
housing.
• Necessity of ESA – a statement that the student needs the ESA because it provides
therapeutic emotional support to alleviate a symptom or effect of the disability of the
student and not merely as a pet. Please include specifically how the ESA mitigates the
symptoms or effects of a disability. Documentation should be specifically written to
provide support for an ESA in Black Hills State University Housing.
Please also note the following:
• Approved Emotional Support Animals must be under the control of their handler, at all times.
• Emotional Support Animals may be excluded if they pose a direct threat to the health and/or
safety of others. Emotional Support Animals that are not under the control of their
owner/guardian or who disrupt other guests may be considered a nuisance and will be asked to
leave. Nuisance behavior could be any of the following examples or any other behavior that
disrupts other guests, patrons, students, or employees. Examples: consistent non-stop barking,
growling, making noise, giving off offensive odors, chewing.
• Emotional Support Animals are subject to the Black Hills State University Policy 3.3: Service
Animals and Assistance Animals. Exotic or wild animals may not be allowed under the state,
county and city laws.
• The Emotional Support Animal handler must maintain sanitary conditions and clean any
Page 2 of 4
animal excretions (or eliminate waste) in public (or surrounding areas).
• An approval for an Emotional Support Animal only applies to housing and does not permit
owner to bring animal to other areas on campus where pets are normally prohibited.
• Handler is responsible for any and all damage to apartments or University property associated
with the Emotional Support Animal.
Today’s Date:
First Name: Last Name:
BHSU ID#: BHSU Email:
Phone Number:
Your campus residence:
Your hometown: Date of birth:
Your class year:
Freshman
Sophomore
Junior Senior
Type of Animal Requested:
What is the specific disability upon which this request is based? (Please attach documentation)
When was this disability diagnosed? (Please attach documentation)
By what type health care professional provided this diagnosis? (Please attach documentation)
In your own words, please provide a brief explanation of how the requested animal relates to your
ability to use and enjoy the living arrangements provided through the BHSU’s Residence Life office:
Please initial beside each of the following items and sign below to indicate your understanding of
the Emotional Support Animal (ESA) request process at the University. You should discuss any
questions you may have with the Disability Services Coordinator before signing and submitting
this form.
Revised: 11/12/2020 Page | 3
I understand that University residences have a no-pets policy. An ESA may be an
accommodation under the Fair Housing Act, when necessary to afford an equal opportunity
for qualified students to use and enjoy campus housing.
Note: ESAs will be approved for a student where the student has a physical or mental
impairment that substantially limits one or more major life activities and the animal
provides therapeutic emotional support to alleviate a symptom or effect of the
disability of the student and not merely as a pet.
I understand that I am required to acquire documentation from a health care provider who has
personal knowledge through a professional relationship involving the provision of health care
or disability related services and who are practicing within their ethical, legal, and
professional obligations.
I understand that the documentation I obtain should be typed/printed on official letterhead,
dated, and signed from a licensed and qualified professional (e.g. psychologists,
neuropsychologists, psychiatrists, clinical social workers, licensed counselors, psychiatric
nurse practitioners, and other relevantly trained healthcare professionals). The
documentation should further include the Relevant Third-Party’s contact information and
any professional licensing information. The documentation must include my name.
I understand that my provider's input should address the specific points that will enable
BHSU to fully consider my request. By initialing beside this item and signing at the bottom
of this form I am authorizing BHSU’s Coordinator of Disability Services to directly contact
my provider for further clarification, if deemed necessary to determine my eligibility.
I understand that because there may be significant differences in the therapeutic connections
and level of care associated with different species, I may not substitute a different animal at a
later point without first submitting a revised request form to BHSU’s Coordinator of
Disability Services. This may include providing associated documentation from my health-
care provider.
I understand that generally, only a single ESA will be approved, per qualified student, at any
given time and that other live animals may not be brought onto campus for the purpose of
being fed to an ESA.
I understand that the documents and correspondence related to this ESA request will be
stored electronically by the Office of Disability Services for five years. The content of these
forms and associated documentation will not be shared without my written consent except
with University officials who have a legitimate educational interest, in the event of a health
or safety emergency, or as required by law.
I understand that the crate/cage that is used to contain the animal should be of a size that does
not interfere with access or egress of other students in the room.
I understand that an Emotional Support Animal will not be approved if it would pose an
undue financial or administrative burden on the University; if it poses a direct threat to the
health or safety of others; or would cause substantial physical damage to property that cannot
be reduced or eliminated by a reasonable accommodation.
I understand that my ESA must be contained (caged or crated) any time I am out of the room,
as breed necessitates.
Note: Generally, ESAs should be mature animals accustomed to being left alone for
Page 4 of 4
periods of time. In the case of a dog, it must be at least nine months of age to assure
that it is reliably housebroken and has all of the shots necessary to make it safe to be
around humans and other animals that may be in residence. Animals of any age that
create a disturbance through noise or their behavior may not reside in the residence
halls. An ESA may not be left alone overnight in University Housing, nor except in an
emergency have its care assigned to any individual.
I have reviewed the Spearfish Animal Ordinances, at the following link, and agree to abide by
them, should this Accommodation be granted. https://www.cityofspearfish.com/351/Animal-
Ordinances
I understand that the approval/denial of my ESA request will be sent to my
University email address and that I have a right to appeal the decision by
contacting the Director of Student Success.
I understand that if BHSU’s Coordinator of Disability Services determines that I qualify for
the requested ESA, I am required to meet with the Coordinator of Disability Services, prior
to bringing the approved animal to campus. At this mandatory meeting I will be informed
of my responsibilities within the residence hall (waste disposal, hygiene, behavioral
control, vaccinations, etc.) and any necessary arrangements regarding roommates will be
determined.
Note: An approved ESA is allowed only within your room in Housing and the
common passage areas for entering/leaving your dwelling (e.g., hallways, elevator,
and lobby) while always under your direct control (i.e., caged, carried, or leashed).
ESAs are not permitted in other students' rooms or inside other campus buildings
unless explicitly approved as a separate accommodation by the office of Disability
Services.
I understand that I will not be charged a fee or deposit although I will be responsible for the
costs to repair damages beyond ordinary wear and tear caused by the animal.
I understand that an ESA brought into a campus residence before the proper approval
process, as described above, is complete is a violation of University regulations and I will
be subject to disciplinary action.
I understand my role in the Emotional Support Animal request process and that I may
check the status of my request by contacting the Disability Services Coordinator at:
Jennifer.Lucero@bhsu.edu or (605) 642-6099.
To be considered, the student making the request should return this completed form to the Office
of Disability Services via email attachment (Jennifer.Lucero@bhsu.edu). Forms will be accepted
up to 90 days prior to the desired start date. Please allow, approximately, two weeks to complete
the review process. After this time frame, questions about the status of your request can be made
via the above email.
Student’s Signature Date
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Emotional Support Animal Request Form The Office of (Black Hills State University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document