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: firstname.lastname@example.org
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 employee’s 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)
Date of Birth (YYYY-MM-DD)
HOME ADDRESS: (Street, City, Postal Code)
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?
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
3. General nature of Illness:
4. Is the employee under your direct, continuous and medically appropriate care for the condition requiring the support
5. Is complete recovery expected?
6. What is the expected duration of this accommodation?
If Temporary please provide an applicable timeline
Next Reassessment Date (