Form - Employee Request for Accommodation
With a Support Animal
Occupational Health & Wellness (OHW)
Phone: 519-824-4120 ext. 52647 Fax: 519-780-1796 E-Mail: ohw@uoguelph.ca
The University of Guelph is committed to creating an environment that is accessible and inclusive to all members of the campus community.
The University is also responsible in meeting its legal requirements for accommodations and making every reasonable effort to
accommodate its employees. Please provide the following information to assist us in planning for your request of an accommodation with a
support animal. For additional information regarding support animals on campus, including the definition of support animal,
documentation requirements, responsibilities of handlers, and behavioral expectations of support animals, please read the Animals on
Campus Protocol and the Animals on Campus Procedures.
Confidentiality of personal health information will be protected and will not be released to anyone outside of Occupational Health and
Wellness without the employees written consent, in keeping with our policies and practices. The supervisor will be provided with specific
functional information with associated strategies which will be used to assist in the accommodation process.
Section A: Employee Information: (to be completed by employee)
NAME: (Surname)
(Given Names)
Date of Birth (YYYY-MM-DD)
HOME ADDRESS: (Street, City, Postal Code)
HOME/CONTACT PHONE NO.
DEPARTMENT/COLLEGE
SCHOOL/DEPARTMENT/SERVICE UNIT
JOB TITLE
FACULTY CHAIR/SUPERVISOR PHONE NO.
1. Please provide the species and approximate size of the animal :
2. Has your support animal received appropriate training to assist with your particular disability?
Yes
No
If YES, please provide information regarding the training received (for example, training organization, certificate of
training, proof of registration with an accredited organization etc.) to OHW.
Section B: Medical Information (to be completed by a qualified medical practitioner).
Please be advised that by completing this form you are certifying that the information is true and accurate and is in keeping
with professional standards outlined by the professional and regulatory bodies that govern your practice. You further
understand that all information requested must be fully completed to ensure the employer can determine the employee’s
accommodation.
3. General nature of Illness:
4. Is the employee under your direct, continuous and medically appropriate care for the condition requiring the support
animal?
Yes No
5. Is complete recovery expected?
Yes
No
6. What is the expected duration of this accommodation?
Permanent
Temporary
If Temporary please provide an applicable timeline
Next Reassessment Date (
DD/MM/YYYY):
1 | P a g e
March 2019
Y
)
at ohw@uoguelph.ca or
Name of Patient: _ Date of Birth (DD/MM/YYYY
7. Do you certify that the employee has a medical condition that results in an impairment and subsequent disability and
requires this support animal for reasons related to that disability?
es
No
8. What specific activities require the employee’s use of the support animal while at work?
9. As part of this accommodation is the support animal expected to be with the employee at all times during the work period?
Yes No
If No please explain
By affixing my signature below, I certify that I am a qualified healthcare provider and that I have personally assessed and treated the above
patient/employee. It is my opinion that the information is true and accurate.
TREATMENT PROVIDER NAME: (Please Print) _ ELEPHONE: ___________________ _________
________________________ T
ADDRES
S: __ AX:_____________________________________________________________ F ___
______________________
SIGNATU
RE: _____________________________________________________________ DATE: _____
__________________
Once competed please return by email or fax to Occupational Health and Wellness
(519) 780-1796.
Any costs associated with providing the above information will be the responsibility of the employee.
2 | P a g e
March 2019
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome