Applicant Name:   

Title/Series/Pay Band of Vacancy:

Home Address:

Phone Numbers:

E-mail Address:   

Request date:   

Briefly describe the medical condition requiring accommodation.

Briefly describe the specific accommodation requested.

Explain how the requested accommodation would assist you participating in the job application/selection process.

If this request is time sensitive, please explain.

Requestor Signature ________________________________________
Date ______________

For more information, call 202-874-4370 or e-mail Jay.Young@OCC.treas.gov.

This solicitation and collection of information is authorized by 12 U.S.C. § 482 and Executive Order 13164. Information that is furnished will be used principally to determine the qualification for reasonable accommodation by any employee of the Office of the Comptroller of the Currency (OCC) or applicant for employment with the OCC. The provision of requested information is voluntary. The failure to provide complete and accurate information may, however, result in denial or delay in the granting of an accommodation request.

Disclosures of this information may be made to: (1) the Merit System Protection Board, the Office of Special Counsel, the Federal Labor Relations Authority, the Equal Employment Opportunity Commission, arbitrators, and hearing examiners when relevant and necessary to the performance of authorized functions; (2) the Office of Federal Employees Group Life Insurance, the Federal Thrift Investment Board, and federal, state, and local agencies when necessary to the adjudication of claims under a retirement, insurance, or health benefit program; (3) health insurance carriers for the purpose of determining eligibility for payment of a health benefit claim; (4) courts, adjudicative, and other administrative bodies when relevant to proceedings before any such entity; (5) federal, state, and local agencies: (a) having law enforcement responsibilities when the information is relevant to the investigation of an actual or potential violation of law; or (b) in connection with hiring or retention decisions, the issuance of security clearances, or the conduct of security or suitability investigations; (6) labor organizations recognized under 5 U.S.C. chapter 71 when relevant and necessary to their duties for exclusive representation; (7) a Congressional office when relevant to an inquiry made at the request of the individual to whom the information pertains; (8) OCC contractors; and, (9) the National Archives and Records Administration.