Confirmation Of Reasonable Accommodation Request Form
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1
2Form Approved:
E-MAIL
FOR OFFICIAL USE ONLY WHEN FILLED
OMB No. 0703-0063
Submit
SUBMIT
CONFIRMATION OF REASONABLE ACCOMMODATION REQUEST
PRIVACY ACT STATEMENT
Privacy Act Statement: The collection of this information is authorized by 29 USC 791 et seq. This information will be used to process a request for
reasonable accommodation. As a routine use, the information may be disclosed to: appropriate agency officials processing or otherwise responding to
the request for reasonable accommodation and/or decisions related to such request; an appropriate government agency, domestic or foreign, for law
enforcement purposes; where pertinent, in a legal proceeding to which the DON is a party or has an interest; to a government agency in order to obtain
information relevant to DON decision(s) concerning reasonable accommodation; to a congressional office in order to obtain information relevant to
DON decision(s) concerning reasonable accommodation; to an expert, consultant or other person under contract with the DON to fulfill an agency
function; to an investigator, administrative judge or complaints examiner appointed for the investigation of a formal EEO complaint under 29 CFR 1614;
to the Merit Systems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel practices and other matters
within their jurisdiction; to a labor organization as required by the Federal Labor Management Relations Act; to the Office of Personnel Management in
making determinations related to disability retirement and benefit entitlement; to officials of the Office of Workers' Compensation Programs; to the
Department of Veterans Affairs; to an employee's private treating physician and to medical personnel retained by the DON to provide medical services
in connection with an employee's health or physical condition related to employment; and to the Occupational Safety and Health officials when needed
to perform their duties. Completion of this form is voluntary. If this information is not provided, processing the request for reasonable accommodation
may not be possible.
Request Type:
LOCATION
:
DATE
:
(Physical Location of Requested Reasonable Accommodation)
(DDMMMYYYY)
My Own Behalf
On Behalf Of
PART I Requestor's Information
(To be completed by Requestor or "On Behalf Of" Requestor)
2. ORGANIZATION:
1. NAME
:
(Last, First, Middle Initial)
4. PHONE
):
(DSN and Commercial
3. OFFICE SYMBOL/DEPARTMENT:
COM:
DSN:
5. OFFICIAL E-MAIL ADDRESS:
6. JOB TITLE AND GRADE/RANK:
7. CITIZENSHIP:
8. DESIGNATION OF PERSON
9. OFFICIAL MAILING ADDRESS:
US
FN
MILITARY
CIVILIAN
Other
LN
CONTRACTOR
APPLICANT
10. REASONABLE ACCOMMODATION REQUEST DESCRIPTION AND EXPLAINATION
:
(Please provide a detailed description of your request)
PART II Details for Reasonable Accommodation
(To be completed by Requestor or "On Behalf Of" Requestor)
10a. DESCRIBE ANY IMPACT OF YOUR PRESENT LIMITATIONS ON THE PERFORMANCE OF YOUR DUTIES:
10b. DESCRIBE ANY ACCOMMODATION YOU BELIEVE WOULD ASSIST YOU IN THE PERFORMANCE OF YOUR DUTIES:
SECNAV 12306/1 (Rev. 8-14)
Page 1 of 2
FOR OFFICIAL USE ONLY WHEN FILLED
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