Request for Emotional Support Animal (ESA) in Campus Housing

Process Instructions

University of Texas Southwestern Medical Center (UTSW) provides reasonable housing accommodations for residents with disabilities who demonstrate a verified need for an Emotional Support Animal (ESA). A reasonable accommodation is an exception to university policies that allow equal access to campus housing

Service Animal vs. Emotional Support Animal

Service Animal: A dog trained to perform disability- related tasks. Permitted in public areas. Requires a separate request.

Emotional Support Animal (ESA): Provides emotional/therapeutic support but is not task trained. ESAs are only permitted in assigned campus housing.

Eligibility

You must have an active campus housing contract to request an ESA.

How to Submit a Request

To avoid delays, complete all steps below:

Healthcare Provider Form

Must be completed by a licensed provider actively treating you (e.g., psychologist, psychiatrist, LCSW).

Submit Documentation to OATIX

Submit the completed form to the Office for Access & Title IX :

Email: Accessibility@UTSouthwestern.edu

Fax: (214) 648-4348

Schedule Intake Appointment

After submission, a specialist will reach out to schedule your intake appointment.

Documentation Must Establish

A disability (substantially limits major life activities)

The ESA is necessary for equal housing access

A clear connection between the disability and the ESA’s support

Review Timeline

A decision will be sent via your UTSW email within approximately two (2) weeks after:

A complete request packet is received, and

The intake appointment is completed

Important Reminders

Do not bring an ESA into campus housing until approval is granted.

ESA approval applies only to campus housing, not classrooms or public spaces.

Approved residents must review and comply with the ESA Owner Responsibilities Agreement (see page 4).

For questions, contact Office for Access & Title IX (OATIX) at Accessibility@UTSouthwestern.edu.

Request for emotionAL SUPPORT ANimal (ESA) in campus housing

Requester Information (Completed by Requester)

Section A. Personal Information

Date:

Name:

Mailing Address:	Campus Apt #

Home Phone:	Cell Phone:

Personal Email Address:	UTSW Email Address:

please confirm completion of the following tasks by checking each item, then provide your signature and the date.

REQUIRED

☐Review the Instruction page of this document, and understand the conditions outlined.

☐Review and agree to the Emotional Support Animal Owner Responsibilities Agreement.

☐Review and Complete the Registration Form for Services Dogs or ESAs

OPTIONAL

☐Below is an Authorization to Release Medical Information, which allows a University Representative to correspond with your health care provider about the documentation accompanying your request. This is optional: however, the failure to provide it may result in denial of the request if the documentation provided is not sufficient.

Authorization To Release Medical Information

I have requested an accommodation from The University of Texas Southwestern Medical Center (UTSW). I hereby authorize my health care provider	to provide all information necessary for the evaluation of my request and to communicate directly with the UT Southwestern Office for Access & Title IX (OATIX) in connection with the evaluation of my request.

Requester’s Signature:	Date:

Request for EMOTIONAL SUPPORT Animal (ESA) in Campus Housing

Requester Healthcare Section (Completed by Health care Provider

Name:	UTSW ID #

To properly evaluate how UTSW can best meet the Requester’s need for requesting an ESA in University housing, the University requires specific diagnostic information from a licensed clinical professional or healthcare provider who is directly responsible for the treatment of the Requester’s disability, including the intentional use of an ESA to address specific functional limitations that result from the Requester’s physical or psychological condition(s). The provider completing this form cannot be a relative or the resident. The provider should completely respond to all questions and may attach additional related information.

Section A. Medical Information

Does the Requester, who you have individually examined and treated, have a physical or mental impairment that substantially limits one or more major life activities? ☐No ☐Yes: Provide a diagnosis and describe what major life activities are impaired at the present time:
Identify the disability-related need for an ESA and explain how the animal alleviates one or more of the identified substantially limiting major life activities (thereby reducing the identified symptoms or effects of this individual’s existing disability). What effective alternative accommodation(s) would you recommend?
What type of animal is being requested?
Describe how the condition is currently being treated/managed?

Additional Notes

Please use this section to provide additional details as needed.

Section B. Health Care Provider Information (Completed by Health Care Provider)

This form must be completed by a licensed clinical professional or health care provider familiar with the history and functional limitations of the resident’s condition(s).

☐I am verifying that the Requester’s information above is correct, that the Requester is a patient that I have been treating, and that I am not a relative of the Requester.

Date of Initial Contact with Requester:	Date of Last Office Visit with Requester:

Provider’s Name:	License Number:	State:

Provider Degree and Job Title:

Name of Institution/Agency/Place of Employment:

Address:

Telephone Number:

UTSW Email Address:

Request for Emotional Support Animal (ESA) in campus housing

Emotional Support Animal Owner’s Responsibilities

UT Southwestern Medical Center Residents approved for an Emotional Support Animal (ESA) in campus housing must comply with the following requirements. Failure to meet these responsibilities may result in removal of the ESA from campus housing. For questions, contact the OATIX at StudentAccommodations@UTSouthwestern.edu.

General Requirements

The ESA must remain within the resident’s assigned unit except when taken outside for natural relief.

When out of the unit, the ESA must be leashed, harnessed, or in a carrier.

ESAs are not permitted in other campus buildings or common areas.

Health & Legal Compliance

The resident must comply with all city, county, and state laws, including licensing and vaccinations.

Documentation (e.g., vaccination records) must be provided upon request.

Care & Supervision

The resident is responsible for the daily care, supervision, and control of the ESA.

The ESA must not display aggressive, disruptive, or unsafe behavior.

ESAs may not be left overnight in campus housing without the resident or housed in another resident’s unit.

Cleanliness & Sanitation

The resident must clean up and properly dispose of animal waste.

The unit must be maintained in a clean and sanitary condition, free of odors and pests.

The University may require inspection and pest treatment, with costs billed to the resident if applicable.

Financial Responsibility

The resident is responsible for any damage or injury caused by the ESA.

Charges may apply for repairs beyond normal wear and tear.

Emergency & Absences

The University is not responsible for evacuation or care of the ESA during emergencies.

Residents must make off-campus arrangements if absent overnight or longer.

Ongoing Approval

ESA approval is valid only while the animal is necessary due to the residents’ disability.

The resident must notify OATIX if the ESA is no longer needed or no longer in residence.

A new request is required to replace an ESA.

Housing Obligations

Removal of an ESA does not release the resident from their housing contract. You must fulfill the lease term

Emotion support animal owner’s responsibilities agreement

Acknowledgment and Release of Information Consent Form

By my signature below, I verify that I have read and understand the Emotional Support Animal (ESA) Owner Responsibilities and I agree to comply. I understand that if I fail to meet the requirements set forth in the Agreement, The University of Texas Southwestern Medical Center (“UTSW” or “University”) has the right to remove the Emotional Support Animal from Campus housing, and I will be nonetheless required to fulfill my lease agreement.

I consent to UTSW’s disclosure of information about my Emotional Support Animal to University staff, potential and/or actual roommate(s) and neighbor(s), as needed. I understand that this information will be shared with the intent of preparing for the presence of the Emotional Support Animal and/or resolving any potential issues associated with the presence of the Emotional Support Animal. I will hold UTSW harmless from any liability for disclosing such information.

I further recognize that the presence of the ESA may be noticed by others visiting or residing in Campus housing and agree that University staff may acknowledge the presence of the Emotional Support Animal, and explain that under certain circumstances Emotional Support Animals are permitted for persons with disabilities

Resident Name:

Resident Signature:	Date: