San Francisco Community College District

Reasonable Accommodation Request: Use of a Service Animal

SHORT FORM

(CONFIDENTIAL)

This form is to be used when employee is only requesting the use of a service animal.

The following to be completed by employee:

Name: _______________________________________________________________________

Address: _____________________________________________________________________

City: ____________________________________________ State: ____ Zip Code: __________

Phone: (____) _____________________________________

Please provide us with the name of your health care provider(s) who can assist in this request. If you have additional providers who also have information on this matter, please list that information on a separate sheet of paper and attach it when returning this form to the Title 5/ADA Compliance Office.

Name: _______________________________________________________________________

Address: _____________________________________________________________________

Phone: _________________ Specialty: ____________________________________________

Please explain how you believe this accommodation will enable you to attend City College of San Francisco: (use extra sheets if needed)

______________________________________________________________________________

______________________________________________________________________________

PLEASE RETURN TO: Title 5/ADA Compliance Office

San Francisco Community College District

31 Gough St., Rm 9A

San Francisco, CA 94103

Note: If there is a need for further clarification on this information, you may be contacted by the ADA Coordinator for employee accommodations.