HomeMy WebLinkAboutOCDSB 915 Service Dog For An EmployeeAttachment 1 to Appendix A
OCDSB 915 Human Resources (December 2017)Page 1
OCDSB 915: REQUEST FOR A SERVICE DOG TO ACCOMPANY AN EMPLOYEE
(References: PR.572.HR)
THIS FORM IS TO BE COMPLETED BY THE EMPLOYEE AND SUBMITTED TO EMPLOYEE
WELLNESS.
Name of Employee: EIN:
School: Department:
a) I request that I be authorized to have a service dog accompany me to work.
b)The service dog will provide me with the following assistance (attach documentation
as necessary):
c)Length of time the employee and the service dog have worked together:
d)Duration of the requested intervention
e) Documentation submitted with this request:
i)medical documentation as required by Employee Wellness;
ii)a copy of dog’s registration and training certification with a recognized training
centre;
iii)a copy of current, official vaccination certificate for the dog;
iv) proof of municipal dog licence;
v)a copy of training certification of the Handler (individual responsible for the
dog), if applicable; and
vi)a copy of liability insurance coverage.
I acknowledge that I am responsible for costs for the dog, including, but not limited to,
training, veterinary care, and other related costs.
Signature of employee:
Date: Print name:
Personal information on this form is collected under the authority of sections 58.5(1) and 265 (d) of the
Education Act, R.S.O. 1990, c.E2, as amended, and in accordance with section 29(2) of the Municipal
Freedom of Information and Protection of Privacy Act. This information will be used for the purpose of
consideration for employee accommodation requests. Access to information will be limited to those
supporting and coordinating accommodation plans. Questions about this collection should be directed
to the HR Officer, Employee Wellness.
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