IMGB-E

MSBA/NEPN: IMGB-E

REQUEST ANIMAL-ASSISTED THERAPY DOGS IN SCHOOLS

NAME:______________________________BUILDING: _________________________

DOG'S NAME: _______________________

AGE: ____________WEIGHT: ________BREED: _________

VETERINARIAN RECORDS -SHOTS AND IMMUNIZATIONS

TRAINING/CERTIFICATIONS

RATIONALE/PURPOSE OF AAT DOG

MONITORING THE AAT DOG When the District is requested to allow a visiting animal-assisted therapy dog (AAT dog) on school property, the school may use the following checklist to determine if the animal should be allowed to remain on school property. If any of the questions are answered in the negative, the District may deny the visiting AAT dog access to school property.

Observation Yes No

Animal is clean, well groomed, and does not have an offensive odor. Animal does not urinate or defecate in inappropriate locations. Animal does not solicit attention, visit or annoy any other student or employee. Animal does not vocalize unnecessarily (bark, growl, whine, etc). Animal shows no aggression or hostility. Animal does not solicit or take food or other items. Animal is in good health. Animal is certified and trained, Animal can obey basic commands (sit, lie, stay, etc.).

APPROVED:

DISAPPROVED:

SUPERVISOR SIGNATURE:

BUILDING PRINCIPAL SIGNATURE:

SUPERINTENDENT SIGNATURE: