Dd Form 2987 - Cap Accommodation Request Page 2
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24. ITEM REQUESTED
Include brand name/model and attach any additional information you may have. If you are a Workers Compensation claimant or if you participate
in telework, please attach a copy of your Department of Labor Claim Acceptance Letter or Telework Agreement.
a. ITEM(S) REQUESTED
b. BRAND(S)/MODEL(S)
c. ADDITIONAL INFORMATION
d. WORKERS' COMPENSATION CLAIM
e. DO YOU PARTICIPATE IN
f. IF YES, WILL THIS (THESE) ACCOMMODATION(S) BE
NUMBER (If applicable)
TELEWORK?
USED AT YOUR TELEWORK LOCATION?
YES
NO
YES
NO
5. JUSTIFICATION
a. PLEASE PROVIDE A DETAILED DESCRIPTION OF YOUR DAILY JOB TASKS FOR WHICH THE REQUESTED ITEMS OR SERVICES WILL BE
USED TO SUPPORT:
b. PLEASE DESCRIBE YOUR LIMITATIONS AND HOW THEY IMPACT YOUR ABILITY TO PERFORM YOUR ESSENTIAL JOB FUNCTIONS:
c. PLEASE DESCRIBE ANY ASSISTIVE TECHNOLOGY YOU HAVE USED AND IN WHAT TYPE OF SETTING (i.e., personal, school, on the job):
6. TRAINING COURSE REQUIREMENTS
Note: Complete this section only if you are a DoD employee attending a job-related training course of two or more days.
Interpreting*
CART*
Travel Reimbursement for Personal Assistant**
a. REQUESTED SERVICE (X one)
*Interpreting and CART services are provided for DoD employees to attend job related training lasting two days or longer, but not to exceed two weeks.
Interpreting and CART services are also provided for the first day of employment for DoD employees hired via the Workforce Recruitment Program.
*It is strongly recommended that this completed form, and proof of course enrollment for training related requests, be submitted for consideration at
least 20 business days in advance. Incomplete requests or requests received less than 15 business days in advance will not be considered. Services
are dependent upon many factors, including geographic location and the availability of interpreting and CART professionals. Therefore, services are
not guaranteed.
**Travel Reimbursement for Personal Assistant are for DoD employees ONLY to attend job related training, two (2) or more days in length and not to
exceed two (2) weeks. This request should also be accompanied with a CAP Personal Assistant (PA) Travel Information Form.
b. COURSE/TRAINING SESSION (Attach a course description and proof of registration to this form)
(1) Course/Training Title
(2) Course Location
(3) Dates (From - To (YYYYMMDD))
(4) Start and End Times Each Day
c. ONSITE POINT OF CONTACT
(3) Telephone (Include
(1) Name (Last, First, Middle Initial)
(2) Title
(5) Email
area code)
7. EMPLOYEE OR SERVICE MEMBER SIGNATURE
8. SUPERVISOR/POINT OF CONTACT INFORMATION
(Complete all fields)
c. Telephone/TTY
a. Name (Last, First, Middle Initial)
b. TITLE
d. Email
(Include area code)
DD FORM 2987 (BACK), FEB 2015
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