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R /A [237 0 R 0] /K [16] >> endobj 95 0 obj << /Type /StructElem /S /Figure /P 41 0 R /Pg 11 0 R /A [238 0 R 0] /K [17] >> endobj 96 0 obj << /Type /StructElem /S /Figure /P 41 0 R /Pg 11 0 R /A [239 0 R 0] /K [18] >> endobj 97 0 obj << /Type /StructElem /S /Figure /P 41 0 R /Pg 11 0 R /A [240 0 R 0] /K [19] >> endobj 98 0 obj << /Type /StructElem /S /Figure /P 41 0 R /Pg 11 0 R /A [241 0 R 0] /K [20] >> endobj 99 0 obj << /Type /StructElem /S /Figure /P 41 0 R /Pg 11 0 R /A [242 0 R 0] /K [21] >> endobj 100 0 obj << /Type /StructElem /S /Figure /P 41 0 R /Pg 11 0 R /A [243 0 R 0] /K [22] >> endobj 101 0 obj << /Type /StructElem /S /Figure /P 41 0 R /Pg 11 0 R /A [244 0 R 0] /K [23] >> endobj 102 0 obj << /Type /StructElem /S /H1 /P 42 0 R /T (Information ͬɫ the Proposed ESA) /E (Information ͬɫ the Proposed ESA) /Pg 12 0 R /K [0] >> endobj 103 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Note: There are some restrictions on the kind of animal that can be approved for the residence hall. It is possible the student may be approved for an ESA, based on the information you provide here, but may not be allowed to bring the specific animal named.) /Pg 12 0 R /K [1] >> endobj 104 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Proposed ESA \(if identified\):) /Pg 12 0 R /K [2] >> endobj 105 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Name of Animal: ) /Pg 12 0 R /K [3] >> endobj 106 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Type of Animal: ) /Pg 12 0 R /K [4] >> endobj 107 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Age of Animal: ) /Pg 12 0 R /K [5] >> endobj 108 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Size of cage/crate needed for containment: ) /Pg 12 0 R /K [6] >> endobj 109 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Dogs and cats are most often requested as ESAs, and seem best suited to adapting to the communal living setting of the college residence hall. If another type of animal is being suggested for this student, please explain why you believe that animal is a better choice. ) /Pg 12 0 R /K [7] >> endobj 110 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Is the animal named here one that you specifically recommended as part of treatment for the student, or is it a pet that you believe will have a beneficial effect for the student while in residence on campus?) /Pg 12 0 R /K [8] >> endobj 111 0 obj << /Type /StructElem /S /P /P 42 0 R /E (Is there evidence that an ESA has helped this student in the past or currently? If not, why do you believe this may be an effective support for the student now?) /Pg 12 0 R /K [9] >> endobj 112 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [245 0 R 0] /K [10] >> endobj 113 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [246 0 R 0] /K [11] >> endobj 114 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [247 0 R 0] /K [12] >> endobj 115 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [248 0 R 0] /K [13] >> endobj 116 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [249 0 R 0] /K [14] >> endobj 117 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [250 0 R 0] /K [15] >> endobj 118 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [251 0 R 0] /K [16] >> endobj 119 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [252 0 R 0] /K [17] >> endobj 120 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [253 0 R 0] /K [18] >> endobj 121 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [254 0 R 0] /K [19] >> endobj 122 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [255 0 R 0] /K [20] >> endobj 123 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [256 0 R 0] /K [21] >> endobj 124 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [257 0 R 0] /K [22] >> endobj 125 0 obj << /Type /StructElem /S /Figure /P 42 0 R /Pg 12 0 R /A [258 0 R 0] /K [23] >> endobj 126 0 obj << /Type /StructElem /S /H1 /P 43 0 R /T (If the animal is permanently removed from student housing due to a policy violation \(e.g., injuring someone or destroying property\), what is the expected impact on the student? Please weigh this potential risk against the expected benefits of the accommodation.) /E (If the animal is permanently removed from student housing due to a policy violation \(e.g., injuring someone or destroying property\), what is the expected impact on the student? Please weigh this potential risk against the expected benefits of the accommodation.) /Pg 13 0 R /K [0] >> endobj 127 0 obj << /Type /StructElem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g 13 0 R /K [1] >> endobj 128 0 obj << /Type /StructElem /S /H1 /P 43 0 R /T (This student was provided with a copy of the rules and restrictions surrounding the presence of an animal in residence in the University housing. Has the student shared those restrictions with you?) /E (This student was provided with a copy of the rules and restrictions surrounding the presence of an animal in residence in the University housing. Has the student shared those restrictions with you?) /Pg 13 0 R /K [2] >> endobj 129 0 obj << /Type /StructElem /S /H1 /P 43 0 R /T (Yes No ) /E (Yes No ) /Pg 13 0 R /K [3] >> endobj 130 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [259 0 R 0] /K [4] >> endobj 131 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [260 0 R 0] /K [5] >> endobj 132 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [261 0 R 0] /K [6] >> endobj 133 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [262 0 R 0] /K [7] >> endobj 134 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [263 0 R 0] /K [8] >> endobj 135 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [264 0 R 0] /K [9] >> endobj 136 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [265 0 R 0] /K [10] >> endobj 137 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [266 0 R 0] /K [11] >> endobj 138 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [267 0 R 0] /K [12] >> endobj 139 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [268 0 R 0] /K [13] >> endobj 140 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [269 0 R 0] /K [14] >> endobj 141 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [270 0 R 0] /K [15] >> endobj 142 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [271 0 R 0] /K [16] >> endobj 143 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [272 0 R 0] /K [17] >> endobj 144 0 obj << /Type /StructElem /S /Figure /P 43 0 R /Pg 13 0 R /A [273 0 R 0] /K [18] >> endobj 145 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Thank you for taking the time to complete this form. If we need additional information, we may contact you at a later date. The named student has signed this form \(above\) indicating written permission to share additional information with us in support of the request. ) /Pg 14 0 R /K [0] >> endobj 146 0 obj << /Type /StructElem /S /P /P 44 0 R /E (We recognize that having an ESA in the residence hall can be a real benefit for someone with a significant mental health disorder, but the practical limitations of our housing arrangements make it necessary to carefully consider the impact of the request for an ESA on the student, the animal, and the campus community. ) /Pg 14 0 R /K [1] >> endobj 147 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Please provide contact information, sign and date this questionnaire \(below\), and return it to the ͬɫ Office of Disability Resources via one of the methods listed below.) /Pg 14 0 R /K [2] >> endobj 148 0 obj << /Type /StructElem /S /H1 /P 44 0 R /T (Healthcare Provider Information) /E (Healthcare Provider Information) /Pg 14 0 R /K [3] >> endobj 149 0 obj << /Type /StructElem /S /P /P 44 0 R /E (I verify that the above-named student information is correct, the student is a patient or client that I have been treating, and I am not in a dual relationship with the student \(relative, friend, etc.\). ) /Pg 14 0 R /K [4] >> endobj 150 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Healthcare Provider Name: ) /Pg 14 0 R /K [5] >> endobj 151 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Agency/Institution: ) /Pg 14 0 R /K [6] >> endobj 152 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Address: ) /Pg 14 0 R /K [7] >> endobj 153 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Telephone Number \(with area code\): ) /Pg 14 0 R /K [8] >> endobj 154 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Healthcare Provider Signature: Date: ) /Pg 14 0 R /K [9] >> endobj 155 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Please return this form and any applicable documentation to: ) /Pg 14 0 R /K [10] >> endobj 156 0 obj << /Type /StructElem /S /P /P 44 0 R /E (Anna Anderson, Disability Resource Coordinator ) /Pg 14 0 R /K [11] >> endobj 157 0 obj << /Type /StructElem /S /P /P 44 0 R /E (disability.resources@ic.edu \(preferred\) ) /Pg 14 0 R /K [12] >> endobj 158 0 obj << /Type /StructElem /S /P /P 44 0 R /E (1101 West College Avenue, Jacksonville, IL 62650 ) /Pg 14 0 R /K [13] >> endobj 159 0 obj << /Type /StructElem /S /P /P 44 0 R /E /Pg 14 0 R /K [14] >> endobj 160 0 obj << /Type /StructElem /S /Figure /P 44 0 R /Pg 14 0 R /A [274 0 R 0] /K [15] >> endobj 161 0 obj << /Type /StructElem /S /Figure /P 44 0 R /Pg 14 0 R /A [275 0 R 0] /K [16] >> endobj 162 0 obj << /Type /StructElem /S /Figure /P 44 0 R /Pg 14 0 R /A [276 0 R 0] /K [17] >> endobj 163 0 obj << /Type /StructElem /S /Figure /P 44 0 R /Pg 14 0 R /A [277 0 R 0] /K [18] >> endobj 164 0 obj << /Type /StructElem /S /TH /P 165 0 R /ID (elem0_LB8jDdgGCvmFd1mf-A1) /A [278 0 R 0] /K 48 0 R >> endobj 165 0 obj << /Type /StructElem /S /TR /P 166 0 R /ID (elem1_LB8jDdgGCvmFd1mf) /K 164 0 R >> 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283 0 R /Next 332 0 R >> endobj 309 0 obj << /Title (This student was provided with a copy of the rules and restrictions surrounding the presence of an animal in residence in the University housing. 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