Emotional Support Animal Request Form

THIS FORM IS ONLY FOR REQUESTING AN EMOTIONAL SUPPORT ANIMAL

EIU will accept and consider requests for reasonable accommodation in University housing at any time. The resident making the request for accommodation should complete and provide the Accommodation Request Form as soon as practicably possible before moving into University housing. However, if the request for accommodation is made fewer than 60 calendar days before the resident intends to move into University housing, EIU cannot guarantee that it will be able to meet the resident’s accommodation needs during the first semester or term of occupancy.

Please note, it may take up to 4 weeks for your request to be processed once all necessary documentation has been received.

This form and any attached documentation are received by the Office of Accessibility and Accommodations and may be shared with University Housing and Dining Services staff as needed.

Name Name First Last
DOB DOB / MM / DD YYYY
E#
Phone Phone - ### - ### ####
EIU Email
What is the first semester for which you are requesting the ESA? (ex. Fall 2026, Spring 2027, etc.)
What is your understanding of the purpose of an ESA?
Do you have a mental health disability?

Do you have a mental health disability? Yes No
Has a medical/mental health professional prescribed the ESA as part of your ongoing mental health treatment plan?

Has a medical/mental health professional prescribed the ESA as part of your ongoing mental health treatment plan? Yes No
Why are you asking for an ESA at this time?
How do you think having an ESA will help you in dealing with your mental health concerns?
What type of animal are you requesting?
As noted in the policy, your ESA must be caged or crated when you are not in your room. Are you concerned at all about leaving your ESA alone in a crate for long periods of time?
As noted in the policy, you are not allowed to leave your ESA in someone else’s care on campus. If you leave campus for a night or a weekend, you must either take the animal with you or find someplace off campus for your ESA to stay. Have you identified someone who can take the ESA for you? This cannot be your roommate.
Attach appropriate documentation from your medical/mental health provider showing that the animal is prescribed as part of an ongoing treatment plan. The EIU Provider ESA Verification Form does not have to be used, but EIU reserves the right to determine if the documentation provides sufficient information.

Attach Files
Please read and sign
Confidentiality Notice
The Office of Accessibility and Accommodations at Eastern Illinois University is committed to ensuring that all information and communication pertaining to a student's disability is maintained as confidential as required or permitted by law. The following guidelines about the treatment of such information have been adopted by the OAA and will be shared with students. These guidelines incorporate relevant state and federal regulations. 1. No one will have immediate access to student files in the OAA except appropriate staff of the OAA. Any information regarding a disability is considered confidential and will be shared only with others within the university who have a legitimate educational interest. 2. This information is protected by the Family Educational Rights and Privacy Act (FERPA). 3. Sensitive information in OAA files will not be released except in accordance with federal and state laws. 4. A student's file may be released pursuant to a court order or subpoena. 5. If a student wishes to have information about their disability shared with others outside the university, the student must provide written authorization to the OAA to release the information. The student should also understand that there may be occasions when the OAA staff will share information with institutional personnel regarding a student's disability at their discretion if circumstances necessitate the sharing of information and the OAA staff have determined that there is an appropriate legitimate educational interest involved. 6. A student has the right to review their own OAA file with reasonable notification.
I have been informed of the policy regarding confidentiality and the release of information from my OAA file. I understand that OAA may release information from my file to be used in a confidential manner with appropriate university faculty and officials who have a legitimate educational interest while I am a student at Eastern Illinois University.
I understand that accommodations are not considered reasonable if it changes the essential elements of the curriculum or results in undue hardship, considering the nature, cost, and impact of the accommodation. I understand that specific information is required for documentation of disabilities and that accommodations will only be considered after a disability has been verified according to the Office of Accessibility and Accommodations documentation requirements. I have reviewed the appropriate policies and guidelines on the OAA website pertaining to my specific accommodation requests.
I acknowledge that I have read and understand the terms of this agreement as detailed above.
Date Date / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
If you need assistance completing this form, please contact the Office of Accessibility and Accommodations at accommodations@eiu.edu or 217-581-6583. NOTE: This form has been approved for use as of June April 1, 2026. The institution reserves the right to update this form, as appropriate, at any time.

Emotional Support Animal Request Form

Emotional Support Animal Request Form

Please read and sign