Iowa Admin. Code r. 161—9 § 161—appendix_a

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 _______________________________
permit me 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.