Fillable Dd Form 2987 - Cap Accommodation Request printable pdf download

COMPUTER/ELECTRONIC ACCOMMODATIONS PROGRAM (CAP) ACCOMMODATION REQUEST

PRIVACY ACT STATEMENT

This statement serves to inform you of the purpose for collecting personal information required by the CAP Portal and how it will be used.

AUTHORITY: 10 U.S.C. 1582, Assistive Technology, Assistive Technology Devices, and Assistive Technology Services; 29 U.S.C. 794d, Electronic

and Information Technology; 42 U.S.C. Chapter 126, Equal Opportunity for Individuals With Disabilities; and DoD Instruction 6025.22, Assistive

Technology (AT) for Wounded, Ill, and Injured Service Members.

PRINCIPAL PURPOSE(S): To collect information from an individual in order to determine whether that individual qualifies for the CAP and what

assistive technology is appropriate for that individual.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the records

may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Collected information may be disclosed to

Federal Government agencies partnered with CAP in order for each agency to meet requirements outlined in its CAP partnership agreement.

Information may be provided to CAP Representatives (see links below) in the requesting individual's agency, as well as supervisors or others whose

contact information is entered into the CAP Accommodation Request form. Information may be provided to commercial vendors to permit the vendor to

identify and provide assistive technology solutions for individuals with disabilities. The applicable system of records notice is DHRA 15 DoD, Computer/

Electronic Accommodations Program, and is located at:

dhra-15-dod/

DoD Agency CAP Representatives:

Non-DoD Partners A-L:

Non-DoD Partners M-Z:

DISCLOSURE: Voluntary. However, failure to provide the requested information may result in you being considered ineligible for any CAP services.

INSTRUCTIONS

Complete this form to request assistive technology and services. Please ensure completion of all contact information. If you have

any questions, please call CAP at (703) 614-8416 (V), or email cap@mail.mil. You may also complete the request form online at

to expedite request processing.

Only individuals who are Department of Defense employees (to include Active Duty Service members), or employees of Federal

Government agencies partnered with CAP are eligible for CAP services. If you are a disabled veteran and are not employed by the

Federal government, please contact the Department of Veterans Affairs for assistance.

1. PERSON TO BE ACCOMMODATED

b. HAVE YOU USED CAP SERVICES BEFORE?

a. NAME (Last, First, Middle Initial)

YES

2. DELIVERY AND CONTACT INFORMATION

(Do not use acronyms or Post Office boxes)

a. AGENCY

DoD

Non-DoD

Specify Agency:

b. DELIVERY ADDRESS (Work address)

(1) Line 1

(2) Line 2

(3) City

(4) State

(5) ZIP Code

c. CONTACT INFORMATION

(1) Telephone/TTY

(2) Fax (Include area code)

(3) Email

(4) Secondary Email

(Include area code)

3. DISABILITY INFORMATION

a. WHAT ARE THE FUNCTIONAL LIMITATIONS RELATED TO YOUR TASK(S)? (X all that apply)

Blind (e.g., legally blind)

Low Vision (e.g., difficulty seeing characters on a screen or printed page)

Cognitive (e.g., difficulty focusing on printed or spoken information, expressing information, remembering things)

Communication (e.g., difficulty communicating)

Deaf/Hard of Hearing (all degrees of hearing loss)

Dexterity (e.g., wrist, neck, back or leg discomfort, paralysis, fine motor skill problems)

Specify condition:

b. ARE YOU CURRENTLY ON ACTIVE DUTY WITH THE U.S.

c. WERE YOU INJURED WHILE ON ACTIVE DUTY WITH THE U.S.

MILITARY?

YES

DD FORM 2987, FEB 2015

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Dd Form 2987 - Cap Accommodation Request

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