Dog Training & Behavioral Advice

 Date:______________________ Physicians name:_________________________ Physicians License Number:________________________________ To whom it may concern,     My patient ___________ is disabled as defined by the Americans With Disabilities Act, Fair Housing Act, Air Carrier Access Act, and Section 504 of the Rehabilitation Act of 1973. The use of a service dog is required in order to mitigate the symptoms of their disability.  If you have any questions please contact me at ___________ and and I will do my best to answer them within the realm of confidentiality. Thank you, Signature Date     

  Date: ________________________ Employee's Name: __________________________________________ Phone: ________________________       Email:_________________________ Job title: _______________________       Department:____________________ Supervisor's name: __________________________________________ I am requesting the following reasonable accommodation(s): Please see the following attached documents:  list of documents supporting your request that have been attached Answer to the two ADA questions: Is the dog a service dog required for a disability?        2. What work or task has the dog been trained to perform?                     Employee signature: _________________________________________ Date: ___________ Links for you to print and add: https://www.eeoc.gov/newsroom/eeoc-sues-hobby-lobby-disability-discimination https://www.ada.gov/regs2010/service_animal_qa.html https://beta.ada.gov/topics/service-animals/ https://www.ada.gov/service_animals_2010.htm