CAP Accommodation Request Form
Complete this form to request assistive technology and services. Please ensure completion of all contact information. Approval is required from requester's supervisor. Signature certifies that the accommodation is necessary for a person with a disabling condition to accomplish an essential job requirement. Signature also verifies that the item requested becomes the property of the receiving Federal Agency. Furthermore, equipment maintenance beyond initial warranty period and additional supplies after receipt of equipment is the responsibility of the Federal agency. If you have any questions, please call CAP at 703-681-8813 (V) 703-681-0881 (TTY), or email CAP@tma.osd.mil.
Complete the form online at http://www.tricare.osd.mil/cap/requests/accommodation_req_form.cfm
or you may fax completed form to 703-681-9075.
You may also send by US Mail to:
DoD Computer/Electronic Accommodations Program Office
TRICARE Management Activity
5111 Leesburg Pike, Five Skyline Place, Suite 810
Falls Church, VA 22041-3206
www. tricare.osd.mil/cap
1. NAME OF PERSON OR OFFICE TO BE ACCOMMODATED (PLEASE PRINT):
_________________________________________________________________________________________
Grade Level: _____ Occupational Series: _____ Are you a new federal employee? _____
Have you used CAP services before? [ ] Yes [ ] No
Please include your CUSTOMER ID # (if known)_________________________
2. ADDRESS/CONTACT INFORMATION: (No P.O. Boxes - No acronyms)
If your agency is within DoD (specify): _________________________
Organization: [ ] Army [ ] Navy [ ] Air Force
If your agency or department is not a DoD Agency (specify name): ___________________________________
DELIVERY ADDRESS:
Address1: ___________________________________
Address2: ___________________________________
City, State, Zip: ___________________________________
Telephone/TTY#: (please indicate which)___________________________________
Fax #_______________________________ Email Address:___________________________________
3. DISABILITY INFORMATION: Identify your disability (Deaf/Hard of Hearing, Blind/Low Vision*, Cognitive, Dexterity*)
Other (explain)___________________________________
*Dexterity Disability (explain) ___________________________________
*Medical documentation is required if you are requesting equipment for an ergonomic disability or a large monitor for legal blindness.
If you are a Workers' Compensation claimant, include your Workers' Compensation Claim # and copy of Department of Labor Claim Acceptance Letter:____________________________________________________
If you are Flexiplace, include your agency agreement form.
Please fax supporting documents to 703-681-9075.
4. SUPERVISOR/POINT OF CONTACT INFORMATION (Complete all fields):
Name (print): _____________________ Signature: ___________________
Telephone/TTY #: __________________ Fax #:_________________
Email: ___________________________________
E Q U I P M E N T
5. ITEM REQUESTED: Include brand name/model and attach any vendor information/brochures you may
have. If requesting Speech Recognition Software, complete and fax the Speech Recognition Information Form, located under "News/Documents" on the CAP website.
6. JUSTIFICATION: Please explain how this item will assist you in performing the essential functions of
your job.
7. OPERATING SYSTEM: In order to establish compatibility, identify your computer operating system:
Win00___ Win98___ Win ME___ WinNT___ Win95___ Mac ___ Other___
8. EMPLOYEE SIGNATURE: _______________________________________________________________
F U N D E D S E R V I C E
Note: Complete this section only if you are requesting one of our funded services, which are: Reader, Interpreter, or Personal Assistant. A training session or travel must last two or more days. Submit a fully completed request at least 15 days prior to the start of the training or travel. Complete both sections A and B.
Identify which funded service you are requesting from the list above_
A. TRAINING SESSION:
Who is providing the training? (please check one) [ ] Private Company [ ] Government Agency
Training/Course Title: _______________________________
Course Location: _______________________________
Course Dates: __________________________________Course Time: _______________________________
Have you been officially registered for training? ___________________________________________________
B. INFORMATION ON SERVICE PROVIDER (INTERPRETERS, READERS, ETC.):
For interpreting service information refer to the CAP Interpreter Database, located under "Deaf Accommodation Services" on the website and for information on obtaining a personal assistant please refer to the CAP Personal Assistant Guidelines, located under "Documents" on the website.
Agency/Service Provider Name, Point of Contact and Address:
_________________________________________________________________________________________
Telephone/TTY #: ______________________________ Fax #: _____________________________________
Cost/Quote (please attach): _____________________ Does service accept Credit Card Payment? _________
E-Mail: ____________________ Website: ________________________________________
Submitting this form signifies you agree to CAP terms and conditions.
Please fill out the above form and then fax it to the Department of the Interior's ATC at 202-208-5174
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