Assistance Dog Approvals
Policy and application form
Assistance Dog Approvals, October 2014 - page 1
Contents
Assistance Dog Approvals Policy ................................................................................3
1.
Policy ..............................................................................................................3
2.
Definitions .......................................................................................................3
3.
Approvals ........................................................................................................4
4.
Conditions .......................................................................................................5
For more information, please contact:............................................................ 6
Assistance Dog Application Information ......................................................................7
How to complete the application forms ........................................................................7
Cardholder Terms and Conditions ...............................................................................8
Assistance Dog Application .........................................................................................9
Form 1 – Applicant’s information .................................................................................9
Form 2 – Dog Information and Training ..................................................................... 12
Assistance Dog Application ....................................................................................... 16
Form 3 – Disability Declaration .................................................................................. 16
Assistance Dog Application ....................................................................................... 20
Form 4 – Veterinarian’s declaration ........................................................................... 20
Assistance Dog Application ....................................................................................... 21
Form 5 – Applicant’s declaration and statement ........................................................ 21
Assistance Dog Approvals, October 2014 - page 2
Assistance Dog Approvals Policy
1.
Policy
1.1.
On behalf of the Minister for Local Government; Community Services; Seniors
and Volunteering; Youth, the Department of Local Government and
Communities shall provide a fair and unbiased assessment of all applications
made under section 8(3) of the Dog Act 1976.
1.2.
All applications will be considered on a case by case basis.
1.3.
In assessing an application, the Department shall also consider the safety of
Public Transport Authority employees, and safety and comfort of the travelling
public.
1.4.
In assessing an application, the Department shall also give fair consideration
to the provisions of the Disability Discrimination Act 1992 (DDA 1992).
1.5.
Dogs can be approved as Assistance Dogs, Assistance Dogs in Training, or
Privately Trained Assistance Dogs.
2.
Definitions
2.1.
Approved person – means a person who is trained, qualified and competent to
administer a public access test for an assistance dog. This can be an
employee of a recognised organisation or an approved independent public
access test assessor.
2.2.
Accredited Organisation – means an organisation that trains and places
Assistance Dogs and is an accredited member of Assistance Dogs
International Incorporated (ADII).
2.3.
Assistance Dog – means any dog, as provided for under section 8(1) of the
Dog Act 1976, which has been specifically trained to assist a person to
alleviate the effect of a disability.
Assistance Dog Approvals, October 2014 - page 3
2.4.
Assistance Dog in training – means any dog as provided for under section 8(1)
of the Dog Act 1976, which has made significant progress towards being
specifically trained to assist a person to alleviate the effect of a disability.
2.5.
Privately Trained Assistance Dog – means any dog as provided for under
section 8(1) of the Dog Act 1976, which is trained by an individual, owner or
handler, who is not affiliated with a recognised organisation.
2.6.
Recognised Organisation – means an organisation that trains and places
Assistance Dogs, which includes:
a) Assistance Dogs Australia;
b) Lions Hearing Dogs Incorporated;
c) Guide Dogs Australia;
d) Seeing Eye Dogs Australia.
3.
Approvals
3.1.
All applications for Assistance Dogs must include the following:
a) An electronic copy of an easily identifiable head photograph of the dog;
b) An electronic copy of an easily identifiable head photograph of the
owner/handler;
c) The name of the person who will be handling the dog;
d) Supporting evidence that the dog has been trained to achieve the
following:
o A high standard of appropriate behaviour fit for a public place;
o A high standard of hygiene fit for a public place;
o Experience in real life situations;
o Non-barking behaviour;
o Toileting on command;
o Travelling in confined spaces on all forms of public transport;
o No reaction to noise, crowds and stressful situations;
o Bark on command if it needs to attract attention for help; and
o Three different tasks that alleviate the owner’s disability
(name the tasks)
Assistance Dog Approvals, October 2014 - page 4
Applications for Assistance Dogs in Training must be supported by:
a) a written statement from an Accredited Organisation confirming that it is
an Accredited Organisation; or
b) a written statement from an Approved person or a Recognised
Organisation that the Assistance Dog in Training has significantly
progressed towards achieving the criteria listed at 3.1(d).
3.2.
Applications for Privately Trained Assistance Dogs, or Assistance Dogs which
are not placed by an Accredited or Recognised Organisation will be
considered, however, applicants must provide:
a) a certificate from a medical practitioner, allied health professional or
disability service provider confirming the person’s disability and how the
Assistance Dog alleviates the effects of that Disability; and
b) a written statement from an Accredited Organisation, Recognised
Organisation or approved person confirming the Assistance Dog has been
trained to achieve the criteria listed at 3.1(d); and
c) written statements of support from any other organisations (eg. airlines or
hotels) that have, in good faith, allowed the dog access to their
premises/facilities
d) a copy of the Public Access Test certification completed by an Approved
Person.
4.
Conditions
4.1.
Additional conditions and limitations may be placed on any approval, at the
discretion of the Minister
4.2.
The approval may be amended or revoked at any time by the Minister
4.3.
Approval will provide the dog and named person, or trainer, access to any
building or place open to or used by the public for any purpose, or in any
public transport.
4.4.
Following an approval, the photograph of the dog and owner/handler will be
placed onto an identification card which must be carried on the named person
at all times. It will be valid for 2 years for Assistance Dogs and 12 months for
Assistance Dog Approvals, October 2014 - page 5
Assistance Dogs in Training from the date of issue, unless stated otherwise
along with any other conditions.
4.5.
Assistance Dogs, Assistance Dogs in Training, and Privately Trained
Assistance Dogs that are approved must be clearly identified by a suitably
marked dog coat or harness.
4.6.
Access may be refused to a public area or public transport if:
a) the person in charge of the public area or public transport cannot properly
identify the dog or named person;
b) a belief that the dog has an infectious disease which could likely
jeopardise
public health or the health of other animals (S5.54A (4) DDA 1992);
c) the dog displays behaviour that breaches the standards of behaviour
required of an Assistance Dog as stipulated in paragraph 3.1(d).
For more information, please contact:
Department of Local Government and Communities
Postal Address: GPO Box R1250, Perth, WA, 6844
Telephone: (08) 6551 8700
Fax: (08) 6552 1555
Email: info@dlgc.wa.gov.au
Web: www.dlgc.wa.gov.au
Assistance Dog Approvals, October 2014 - page 6
Assistance Dog Application Information
How to complete the application forms
1. Either the applicant and/or guardian/agent are to complete Forms 1, 2 and 5.
2. The applicant’s medical practitioner, allied health professional or disability service
provider (where applicable) is to complete Form 3.
3. The applicant’s Veterinarian is to complete Form 4 (for owner trained assistance
dogs).
4. All application forms and relevant supporting documents (including electronic
photos) are to be submitted to:
Assistance Dog Applications
Department of Local Government and Communities
GPO Box R1250
PERTH WA 6844
Email: info@dlgc.wa.gov.au
If you have any further queries about the application or the approval process you can
contact the Department of Local Government and Communities (Governance and
Legislation Division) on: Telephone: (08) 6551 8700
Please note that:

Any incorrect or misleading statement in this application may result in the
immediate cancellation of any assistance dog approval.

Original applications and photographs cannot be returned under any
circumstances.

Incomplete applications, including those without signatures, cannot be
processed.

If successful in qualifying for the Assistance Dog Card, your card will be
posted out to you.
Assistance Dog Approvals, October 2014 - page 7
Cardholder Terms and Conditions
The following terms and conditions apply:

An Assistance Dog approval allows any dog approved under section 8(3) of
the Dog Act 1976 to enter any building or place open to or used by the public,
for any purpose, or in any public transport.

The cardholder must carry their Assistance Dog and Handler Identity Cards
with them at all times and the card shall be produced if requested by an
authorised person, including employees of the Public Transport Authority.

The Assistance Dog shall be suitable for travelling on public transport, which
can be over a long distance with extended travel times. At all times, the
Assistance Dog shall be under the control of the cardholder.

The cardholder must understand that trains, buses and coaches could be
crowded and noisy for a dog, and therefore the Assistance Dog must be able
to cope with these movements and noise.

The Assistance Dog shall be trained in accordance with the criteria set in this
Policy.

The cardholder will be responsible for any injury, loss or damage however
caused, or contributed to, by the Assistance Dog at any building, place or
transport.
Approved Assistance Dogs, when in a public building, place or transport,
shall not:
 Cause any distress or inconvenience to any other person;
 Cause any risk to the health, safety and welfare of any person, passenger or
staff;
 Disrupt the operations of services;
 Sit on seats or where services are provided;
 Block doorways or aisles;
 Toilet on seats, service areas or in premises or in public transport.
Assistance Dog Approvals, October 2014 - page 8
Assistance Dog Application
Form 1 – Applicant’s information
To be completed by applicant or guardian.
Applicant / Guardian:
Title:
[Click here to enter text.]
Given Name(s):
[Enter text.]
Surname:
[Click here to enter text.]
Gender:
[Click here to enter text.]
Telephone:
[Click here to enter text.]
Email:
[Click here to enter text.]
Residential
Address:
[Click here to enter text.]
Suburb:
[Click here to enter text.]
State:
[Click here to enter text.]
Postal Address
(if different):
[Click here to enter text.]
Suburb:
[Click here to enter text.]
State:
[Click here to enter text.]
Assistance Dog Approvals, October 2014 - page 9
Date of Birth:
[Enter text.]
Postcode:
[Enter text.]
Postcode:
[Enter text.]
Please tick the boxes that best describe your disability. We have provided
some examples of disability to assist you. (You can tick more than one box.)
☐Physical (Eg. Muscular Dystrophy, Quadriplegia, Cerebral Palsy)
Description: [Click here to enter text.]
☐ Sensory (Eg. Deaf, Blind)
Description: [Click here to enter text.]
☐ Intellectual (Eg: Down Syndrome, Rhetts Syndrome)
Description: [Click here to enter text.]
☐ Neurological (Eg. Alzheimer’s Disease, Huntington’s Disease)
Description: [Click here to enter text.]
☐ Acquired Brain Injury (Eg: Stroke, Head injury)
Description: [Click here to enter text.]
Assistance Dog Approvals, October 2014 - page 10
☐ Psychiatric (Eg: Schizophrenia)
Description: [Click here to enter text.]
☐ Other
Description: [Click here to enter text.]
Why do you require an assistance dog, or how will an assistance dog assist
you to be more independent?
[Click here to enter text.]
Assistance Dog Approvals, October 2014 - page 11
Assistance Dog Application
Form 2 – Dog Information and Training
To be completed by the applicant, guardian or agent.
What is the Assistance Dog’s name?
[Click here to enter text.]
Part 1 – Accredited Organisation Trained
Has your Assistance Dog been trained and placed by an Accredited
Organisation?
☐ No.
If “no”, please go to Part 2.
☐ Yes.
If “yes”, please provide a written statement from the Accredited Organisation
confirming that it is accredited, as well as details of the Accredited Organisation
below:
Organisation
Name:
[Click here to enter text.]
Contact Name:
[Click here to enter text.]
Position in
Organisation:
[Click here to enter text.]
Telephone:
[Click here to enter text.]
Email:
[Click here to enter text.]
Address:
[Click here to enter text.]
Suburb:
[Click here to enter text.]
State:
[Click here to enter text.]
Assistance Dog Approvals, October 2014 - page 12
Postcode:
[Enter text.]
Please provide a written statement from the Approved Person confirming that
the Assistance Dog is able to achieve the following:

A high standard of appropriate behaviour fit for a public place;

A high standard of hygiene fit for a public place;

Experience in real life situations;

Non-barking behaviour;

Toileting on command;

Travelling in confined spaces on all forms of public transport;

No reaction to noise, crowds and stressful situations;

Bark on command if it needs to attract attention for help; and

Three different tasks that alleviate the owner’s disability (name the tasks).
Part 2 – Privately Trained
Has your Assistance Dog been privately trained?
☐ No.
☐ Yes. If “yes”, please provide details of who has primarily conducted the training.
Organisation
Name:
[Click here to enter text.]
Contact Name:
[Click here to enter text.]
Position in
Organisation:
[Click here to enter text.]
Telephone:
[Click here to enter text.]
Email:
[Click here to enter text.]
Address:
[Click here to enter text.]
Suburb:
[Click here to enter text.]
State:
[Click here to enter text.]
Assistance Dog Approvals, October 2014 - page 13
Postcode:
[Enter text.]
Detail dog training qualification and experience:
[Click here to enter text.]
Assistance Dog has been trained to be able to achieve the following (please
tick those which are true):
☐ A high standard of appropriate behaviour fit for a public place.
☐ A high standard of hygiene fit for a public place.
☐ Experience in real life situations.
☐ Non-barking behaviour.
☐ Toileting on command.
☐ Travelling in confined spaces on all forms of public transport.
☐ No reaction to noise, crowds and stressful situations.
☐ Bark on command if it needs to attract attention for help.
☐ Three different tasks that alleviate the owner’s disability. Please name the tasks.
Task 1:
[Click here to enter text.]
Assistance Dog Approvals, October 2014 - page 14
Task 2:
[Click here to enter text.]
Task 3:
[Click here to enter text.]
Part 2 Checklist (Privately Trained):
☐ Please provide at least two (2) written statements of support from any
organisation, private business, or transport provider that has allowed the
Assistance Dog to accompany the applicant on to their premises, or use their
facilities, and can attest to the Assistance Dog possessing the abovementioned
traits.
☐ Include a completed Form 4 (Veterinarian’s Declaration).
☐ Attach a copy of the Public Access Test certification which has been completed
by an Approved Person.
Note: All privately trained assistance dogs must have passed this test to be eligible
for approval.
☐ Please provide details of any other training or experience the Assistance Dog
has had or information in support of your application. (Eg: Public Access
Testing, Obedience Training Certificate, etc)
Assistance Dog Approvals, October 2014 - page 15
Assistance Dog Application
Form 3 – Disability Declaration
To be completed by the applicant’s Medical Practitioner, Allied Health Professional
or Disability Service Provider.
Medical Practitioner, Allied Health Professional or Disability Service
Provider:
Full Name:
[Click here to enter text.]
Business/Employer: [Click here to enter text.]
Position:
[Click here to enter text.]
Telephone:
[Click here to enter text.]
Email:
[Click here to enter text.]
Address:
[Click here to enter text.]
Suburb:
[Click here to enter text.]
State:
[Click here to enter text.]
Postcode:
[Enter text.]
I have seen the applicant in a professional capacity for:
Years:
[Enter text.]
Months:
I advise the nature of the applicant’s disability is (are):
Assistance Dog Approvals, October 2014 - page 16
[Enter text.]
[Click here to enter text.]
I describe in detail the functional impact of the applicant’s
disability/disabilities:
[Click here to enter text.]
I describe the assistance required by the applicant:
Assistance Dog Approvals, October 2014 - page 17
[Click here to enter text.]
The applicant requires the support of an Assistance Dog for what period
of time?:
[Click here to enter text.]
Assistance Dog Approvals, October 2014 - page 18
My signature below confirms all of the following (please tick):
☐ I have read all the relevant information contained within this form, and verify
that it is correct to the best of my knowledge;
☐ I am not the applicant, or an immediate family member of the applicant;
☐ I am the applicant’s Medical Practitioner, Allied Health Professional or
Disability Service Provider; and
☐ I agree to offer all reasonable information to the Department of Local
Government and Communities to assist with the assessment of the
Assistance Dog application to determine the applicant’s eligibility, if required.
Signature:
Assistance Dog Approvals, October 2014 - page 19
Date:
Assistance Dog Application
Form 4 – Veterinarian’s declaration
To be completed by the registered Veterinarian.
Registered Veterinarian:
Full Name:
[Click here to enter text.]
Business/Employer: [Click here to enter text.]
Position:
[Click here to enter text.]
Telephone:
[Click here to enter text.]
Email:
[Click here to enter text.]
Address:
[Click here to enter text.]
Suburb:
[Click here to enter text.]
State:
[Click here to enter text.]
Postcode:
[Enter text.]
My signature below confirms all of the following (please tick):
☐ The Assistance Dog displays standards of hygeine that are appropriate for a
public place and premises, and in public transport.
☐ The Assistance Dog is of good health and has no infectious diseases.
☐ The Assistance Dog displays good standards of behaviour that are
appropriate for an animal in a public place and premises, and in public
transport.
☐ The Assistance Dog responds to control and obedience commands.
Signature:
Assistance Dog Approvals, October 2014 - page 20
Date:
Assistance Dog Application
Form 5 – Applicant’s declaration and statement
In consideration of being granted a permit for my Assistance Dog to be
allowed into any building, place or onto public transport for the period
indicated on the Permit, I agree to and acknowledge the following (please
tick):
☐ I certify that to the best of my knowledge the information in this application is
accurate;
☐ Individual photos of the applicant and the Assistance Dog are attached;
☐ I have an ongoing disability and require an Assistance Dog;
☐ I agree that the Veterinarian, Medical Practitioners, Allied Health
Professionals, Disability Service Provider or Approved Person may disclose
any information relating to this application to the Department of Local
Government and Communities to assist with its assessment; and
☐ I understand and accept the cardholder Terms and Conditions.
Applicant’s Signature:
Signature:
Date:
Agent’s Signature (person who completed this form on behalf of the applicant):
Full Name:
[Click here to enter text.]
Telephone:
[Click here to enter text.]
Email:
[Click here to enter text.]
Assistance Dog Approvals, October 2014 - page 21
Relationship to
Applicant:
[Click here to enter text.]
Signature:
Date:
Legal Guardian’s Signature (if applicant is under 18 years of age):
Full Name:
[Click here to enter text.]
Telephone:
[Click here to enter text.]
Email:
[Click here to enter text.]
Relationship to
Applicant:
[Click here to enter text.]
Signature:
Assistance Dog Approvals, October 2014 - page 22
Date: