Appendix A
(This form cannot be filled in (or submitted) online.)
Applicant or Employee Name: ________________________________________________
Telephone Number: _____________________________
Employee Only:
Occupational Series _______
Grade _______
Applicant or Employee E-mail address: _______________________________________
Date of Request: ________________________
Employee’s Agency: _____________________
1. Accommodation Requested (be as specific as possible)
2. Reason for Request
3. If accommodation is time sensitive, please explain:
This request form shall be given to your immediate supervisor or Mission Area/Agency Disability Employment Program Manager. This form is necessary for recordkeeping purposes only and will not delay the processing of your initial request.
Today’s Date: _______________________________
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