Appendix A

 

Form 1

 

Request for Assistance Animal as a Reasonable Accommodation in Housing:
Health Care Professional Form

 

Requester’s Name: __________________________________________________________

 

Address:____________________________________________________________________

 

Telephone: ______________________ E-mail: _________________________________

 

I, __________________________________, intend to request that _______________________

 

permitme to keep an assistance animal as a reasonable accommodation in housing for my disability. In connection with that application, I am requesting that you complete this form regarding my disability.

 

 

__________________________________                     _______________________________

 

Requester’s Signature                                                   Date

 

 

 

TO BE COMPLETED BY HEALTH CARE PROFESSIONAL

 

 

 

1.         Does the individual identified above have a disability?

 

☐ Yes              ☐ No              

 

2.         If yes, is the need for an assistance animal related to that disability?  For example, does or would an assistance animal alleviate one or more of the symptoms or effects of the disability?

 

☐ Yes              ☐ No              

 

 

 

By signing below, the undersigned health care professional/licensee certifies that he/she 1) has met with the patient or client in person or by telemedicine, 2) is sufficiently familiar with the patient or client and the disability, and 3)  is legally and professionally qualified to make the finding.

 

 

 

Health Care Provider’s Name (printed): ________________________________________________

 

 

 

Signature: _____________________________________________________________________

 

 

 

Date: ________________________________________

 

 

 

References: Iowa Code sections 216.8B and 216.8C

 

Resources: https://icrc.iowa.gov/, 515-281-4121, 1-800-457-4416

 

 

 

This document may contain privileged and confidential information and/or protected health information intended solely for the use by the recipient housing provider. Please exercise care to avoid dissemination.