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UNIVERSITY OF CALIFORNIA SAN DIEGO (University of California, San Diego)

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Page 1 of 3
UNIVERSITY OF CALIFORNIA SAN DIEGO
BERKELEY • DAVIS • IRVINE • LOS ANGELES • MERCED • RIVERSIDE • SAN DIEGO • SAN FRANCISCO SANTA BARBARA • SANTA CRUZ
OFFICE FOR STUDENTS WITH DISABILITIES
TEL: (858) 534-4382
FAX: (858) 534-4650
TDD: (858) 534-9709
Assistance Animal Accommodation Request
The individual below has requested an assistance animal in University owned housing on the basis of a
disability, and has disclosed to the Office for Students with Disabilities (OSD) at UC San Diego that you
are the treating medical provider for his/her health condition. The University considers the reliability of
letters provided to offer verification or certification of the need for an assistance animal and weighs
factors including, but not limited to; the extent of the provider’s knowledge about the individual; the
nature of their relationship; whether that relationship is of an ongoing therapeutic nature; the basis for the
assessment of the individual; the specificity of the letter; and the basis of the assessment that the animal
will ameliorate symptoms. In accordance with professional ethics, this form may not be completed by a
family member.
Individual’s Name _________________________________________ DOB ________________
Spouse/Dependent’s Name___________________________________ DOB________________
TO BE COMPLETED BY THE PROVIDER:
Name/Title of Certifying Professional (Please print)
______________________________________________________________________________
License # ______________________________________ State______________________
A
ddress _______________________________________________________________________
T
elephone Number _____________________________ Fax Number ______________________
P
rovider Certification:
I certify, by my signature below, that I conducted or formally supervised and co-signed the diagnostic
assessment of the individual named above. In cases where the diagnostic assessment of the individual
was performed by another clinician, my signature confirms the review of the original assessment and
agreement of the diagnosis.
OR
Signature _____________________________________ Date__________________________
If you feel you CANNOT provide documentation for this individual, please indicate the reason below:
____ I am not treating this individual ____ I have not diagnosed this individual
____ I have referred to another clinician ____ I have referred for additional evaluation
____ I would need additional sessions with the ____ I have insufficient information to describe
individual to complete this form functional limitations that would impact
____ Other ____________________________________ the individual’s academic work/major life
activities and/or need for an Assistance Animal
9500 GILMAN DRIVE # 0019
LA JOLLA, CALIFORNIA 92093-0019
http://osd.ucsd.edu
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Page 2 of 3
Individual’s Name _________________________________________ DOB _____________
1. What is the initial date of the diagnosis(es)?
_________________________________________________
2. Is the individual currently under your care for this diagnosis(es)? YES NO
3. We generally look for reliable documentation from a provider who has an ongoing
therapeutic relationship with the individual. Please list the dates you treated the
individual within the last 6 months specifically for their mental health diagnosis(es)?
_______________________________________________________________________
4. Does this individual have a current diagnosis as per the DSM-V? YES NO
a. If YES, what factors do you believe would indicate that this condition would be a
disability under the ADA?
5. What are the individual’s current functional limitations?
6. What were the evaluation procedures used to determine these functional limitations?
7. In your professional and objective opinion, how does the animal mitigate these
limitations and in what ways?
Page 3 of 3
8. Have you observed the individual with his/her animal? YES NO
a. If YES, please characterize these interactions. How have you seen the animal
help/assist the individual?
b. If NO, please clarify the basis for concluding that the animal mitigates or will
mitigate the individual’s symptoms.
9. Do you consider the animal to be a necessary component of the individual’s current
treatment plan? YES NO
10. If the animal serves a role in mitigating the impacts of the individual’s disability, please
explain the ways in which the animal’s impact goes beyond the benefits that the typical
individual receives when having/interacting with a pet?
11. The University provides housing accommodations on an annual basis, and therefore, will
need annual updates. How do you plan to assess this individual’s continued need for an
animal and how frequently do you plan to do this?
Based on your observations and opinions of the individual’s limitations, if there other
impacted areas for which you believe the individual would benefit from additional
accommodations and/or if you feel that the individual would benefit from having access
to the assistance/emotional support animal outside of housing, please complete our
Documentation of Psychological Conditions form at https://osd.ucsd.edu/_files/forms-
for-medical-professionals/Documentation-Form-for-Psychological-Disabilities-FINAL-
6.13.19.pdf and submit along with this form.
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UNIVERSITY OF CALIFORNIA SAN DIEGO (University of California, San Diego)

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Completed 7 October 2021

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