viterbologo Request for a Service Animal or Emotional Support Animal (ESA)
          
This form is used for documentation to support a Request for a Service Animal or
Emotional Support Animal (ESA) as a reasonable accommodation in Viterbo housing
(including res halls, apartments and theme houses).
 
 
This form is to be completed by the medical professional who tested, diagnosed and evaluated this student.

Please complete this form to provide needed medical information (diagnosis and prognosis) for this student and
to prescribe a support animal for this student based on diagnosis and testing.
Student Full Name:  
 
Please provide required information: name and credentials of the professional providing this information.
Professional's Name:         
Professional Credentials:     
Professional Phone:     
 
The information below will help determine:
  • Whether this student meets criteria for an individual with a disability according to federal law
  • Appropriate and reasonable accommodations that are supportive of this request
 
1.   Clear statement(s) of the condition(s), including diagnosis and expected duration of the diagnosed condition.
 
2.   The basis for the diagnosis (testing with most recent date) and date of onset of this condition/diagnosis. (Please provide testing results.)
 
3.   The functional impact or limitations that result from this diagnosis.
 
4.   What is the severity of the impact of the condition/diagnosis on the student's performance of major life activities in comparison to most people in the general population?
 
  5. Are you prescribing an ESA based on medical testing and assessment?
 
6.   Recommended accommodation(s).  The student is requesting authorization for use in campus housing for an emotional support or service animal as a reasonable accommodation.  If you believe that an emotional support animal is necessary and vital to the student's health and well-being while living on campus, please explain the basis for your opinion and why you deem an animal is necessary for this student in campus housing.
 
As the student's request for accommodation is being evaluated, I may request additional or more detailed information.
 
My signature below affirms that the information I am providing is true and correct. 
ESignature:  
 
***Please print and retain a copy for your records if needed.  
 
Thank you.,
Jane Eddy  
Director, Academic Resource Center  
Coordinator of Disability Services  
Viterbo University  
608-796-3194 | jleddy@viterbo.edu  
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