Appendix B - Confirmation Of Request For Reasonable Accommodation
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1APPENDIX B
CONFIRMATION OF REQUEST
FOR REASONABLE ACCOMMODATION
1. INDIVIDUAL INFORMATION
Applicant or Employee Name:
Date of Request:
Email:
Phone:
Pay Plan, Series, Grade:
Job Title:
Organization:
Form Completed By:
Date Completed:
Email:
Phone:
2. ACCOMMODATION REQUESTED (Be as specific as possible, e.g., adaptive equipment, reader, interpreter, etc)
3. REASON FOR REQUEST
If accommodation is time sensitive, please explain:
Return Form to Supervisor
(Disability Program Manager will assign Number)
4. LOG NUMBER:
Date:
Note: This form should be completed by the employee making the reasonable accommodation request and provided to his/her
supervisor. An applicant should return the form to any Army employee with whom the applicant has had contact in connection
with the application process. If a third party is completing the form on behalf of the employee or a management official is
documenting an oral reasonable accommodation request, a copy of the completed form will be provided to the employee to
confirm receipt of the reasonable accommodation request. Supervisors must provide a copy of this form to the EEO Disability
Program Manager, who will assign a log number and return a copy of the form to the supervisor.
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