Appendix C
(This form cannot be filled in (or submitted) online.)
Name of Individual Requesting Accommodation:____________________________
1. Type(s) of reasonable accommodation requested:
2. Request for accommodation denied because (may check more than one)
___Accommodation ineffective
___Accommodation would cause undue hardship
___Medical documentation inadequate
___Accommodation would require removal of an Essential Function
___Accommodation would require lowering of performance/production standard
___Other (please specify)
3. Detailed reason(s) for the denial of the accommodation (Must be specific, e.g., why accommodation is ineffective or causes undue hardship)
4. If the requestor proposed one type of reasonable accommodation and the request is denied, and rejected an offer of an alternative accommodation, explain the reason for denial of the original requested accommodation and how the offered alternative accommodation would be effective.
Name & Title of Deciding Official _____________________________
Signature of Deciding Official___________________________________
Date reasonable accommodation denied_____________________________
If an individual wishes to request reconsideration of this decision, s/he may take the following steps:
If an individual wishes to file an EEO complaint, or pursue Merit Systems Protection Board (MSPB) and union grievance procedures if applicable, s/he must take the following steps:
Previous page (Appendix B: Reporting form)|Next page (Appendix D: EEOC)