REASONABLE ACCOMMODATION PROCEDURES

Appendix B
(This form cannot be filled in (or submitted) online.)

REASONABLE ACCOMMODATION INFORMATION REPORTING FORM

Name of Individual Requesting Accommodation:_________________________________

Agency and Office of the Requesting Individual:_________________________________

1. Reasonable Accommodation (check one)

_____ Approved - Name & Title of Deciding Official:_________________________

2. Date accommodation requested and date referred, if applicable:____________________

3. Name & position of individual to whom request was made:_______________________

4. Date accommodation approved or denied:_____________________________________

5. Date accommodation provided:______________________________________________

6. If time frames outlined in the Reasonable Accommodation Procedures were not met, please explain why:

7. Job held or desired by individual requesting accommodation (include occupational series, grade level and office):

8. Accommodation required for:

_____application process

_____performing job functions or accessing work environment

_____accessing a benefit or privilege of employment (e.g., attending training, social event)

9. Type(s) of accommodation requested:

10. Type(s) of accommodation provided:

11. Was medical information required to process this request? If yes, explain why:

12. Cost, if any, of accommodation:

13. Sources of technical assistance, if any, consulted (Job Accommodation Network, family member, rehabilitation counselor, other)

Disability Employment Program Manager (DEPM) Name:________________________

DEPM Signature_______________________________

Date:________________________