Fillable Emotional Support Animal Request Form To be considered, (Morehead State University)

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Emotional Support Animal Request Form To be considered, (Morehead State University)

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Emotional Support Animal Request Form
To be considered, the student making the request should return this completed form to the Disability
Services office (DS) via fax (606-783-9190) or email attachment (e.day@moreheadstate.edu). Forms
will be accepted up to 90 days prior to the desired start date. This is an all-electronic process.
Requests will not be processed in person unless due to disability limitations you need our assistance
to complete the form, or if the DS Coordinator asks to schedule a meeting to better determine your
eligibility.
First Name: ____________________ Last Name: ________________________ Date ____ /____ /
____
MSU ID#: _____________ MSU Email: _______________________________ Ph: _________________
Your campus residence: ____________ Your hometown: ______________ Date of birth: ___/___/
___
Your class year: Freshman Sophomore Junior Senior
Type of Animal Requested: ____________________________
What is your disability on which this request is based? Approximately when was your mental health
disability diagnosed? By what type of professional?_________________________________________
______________________________________________________________________________________
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 MSU Housing 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.
____
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____
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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: Approvals are not granted simply because a disability is established nor for
every type of disability. ESAs will be approved for a student with a mental health disability when
supported by a relevant professional’s opinion that the animal will significantly reduce the impact of
that individual’s symptoms.
You will be responsible for obtaining an ESA recommendation from a local professional (i.e.,
generally within KY or your hometown area) working within his/her area of expertise. The most
appropriate provider will be the health care professional who has been directly involved in the
evaluation and treatment of your mental health disability.
Directions for your health care provider to prepare and submit their input is available on the DS
web site in the same area where you accessed this form. To expedite communication from the
provider, you may wish to sign the release on the last page of their form before giving it to them.
You are responsible for following up with your provider to verify that their input has been
submitted.
Your provider's input should address the relevant points that will enable us to fully consider your
request. By initialing beside this item and signing at the bottom of this form you are authorizing DS
to directly contact your provider for further clarification if we consider it necessary to determine your
eligibility.
Since there may be significant differences in the therapeutic connections and level of care
associated with different species, you may not substitute a different animal at a later point without
first submitting a revised request form to DS; if deemed appropriate, you will be directed to get a
revised recommendation from your health care provider.
Generally, only a single ESA will be approved per qualified student at any given time. Other live
animals may not be brought onto campus for the purpose of being fed to an ESA.
Your submitted forms and correspondence related to the ESA request process will be stored
electronically by the DS office for five years. The content of your forms will not be shared without
your 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.
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 residents in the room.
____
____
____
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____
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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:
e.day@moreheadstate.edu.
Date ____/____/____
______________________________________________________
Typing your name here will serve as an electronic signature.
____
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. ESAs must be contained (caged or crated) any time its owner is out of
the room. Generally, ESAs should be mature animals accustomed to being left alone for 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 other than
its owner.
If your ESA request is denied by Disability Services you will be notified at your University
email address. You will have a right to appeal the decision by contacting the Director of
Housing at 606-783-2060 or housing@moreheadstate.edu.
If Disability Services determines that you qualify for the requested ESA you will be notified at your
University email address. At that point you will be referred to meet with the Assistant Director of
Student Housing prior to bringing the approved animal to campus. At this mandatory meeting you
will be informed of your responsibilities within the residence hall (waste disposal, hygiene, behavioral
control, vaccinations, etc.) and any necessary arrangements regarding roommates will be
determined. You will not be charged a fee or deposit although you will be responsible for the costs to
repair damages beyond ordinary wear and tear caused by the animal. 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 DS office.
An ESA brought into a campus residence before the proper approval process described above is
fully complete is a violation of University regulations and the student will be subject to disciplinary
action.
This request form will be retained for ninety days. If extenuating circumstances delay your ability
to get documentation from your treatment provider, you should inform the DS office; otherwise, a
new request will need to be made if you wish to be considered for an ESA at a later time.
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Emotional Support Animal Request Form To be considered, (Morehead State University)

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Completed 23 July 2021

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