OMB Number: 2900-0767
Respondent Burden: 10 minutes
WRITTEN CONFIRMATION OF REQUEST FOR ACCOMMODATION
An oral request from an employee is sufficient to begin the reasonable accommodation process. Completion of this form is
voluntary. However, individuals who have requested an accommodation are asked to fill out this form for record-keeping
purposes.
The Paperwork Reduction Act (PRA) of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the PRA. We cannot sponsor or require you to respond to a collection of information
unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will
average ten minutes including the time it will take to read the instructions, gather the necessary facts, and fill out the form.
Privacy Act Information: The information requested on this form is solicited under the authority of Executive Order 13164 that
requires the collection of data that will allow measurement and evaluation of the efficiency and appropriateness of the actions taken
by the Department of Veterans Affairs in processing accommodation requests. Information from the data collection will become part
of a System of Records that complies with the Privacy Act of 1974. This System of Records is identified as "Reasonable
Accommodation Processing Records" as set forth in the Compilation of Privacy Act issuances via online GPO access at
gpoaccess.gov/privacyact/index.html.
If you need assistance in completing this form, please contact the Local Reasonable Accommodation Coordinator.
NAME OF EMPLOYEE
PHONE NUMBER OF EMPLOYEE
DATE OF REQUEST
TODAY'S DATE
(Include Area Code)
EMAIL ADDRESS OF EMPLOYEE
OFFICE OF EMPLOYEE
SUPERVISOR'S NAME
SUPERVISOR'S PHONE NUMBER
ACCOMMODATION REQUESTED (Be as specific as possible)
REASON FOR REQUEST
IF ACCOMMODATION IS TIME SENSITIVE, PLEASE EXPLAIN BELOW
Employees should give this form to their immediate supervisor or the LRAC.
NAME OF LRAC
PHONE NUMBER OF LRAC
LOG NUMBER ASSIGNED
This form should be retained separately from the employee's Official Personnel Folder.
0857A
VA FORM
MAR 2011