Confirmation Of Reasonable Accommodation Request Form Page 2
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1
2E-MAIL
FOR OFFICIAL USE ONLY WHEN FILLED
Form Approved:
Submit
SUBMIT
OMB No. 0703-0063
10c. IF REQUEST IS DUE TO A WORK RELATED INJURY, PLEASE PROVIDE WORKER'S COMPENSATION CLAIM #:
10d. DESCRIBE THE NATURE OF YOUR MEDICAL CONDITION AND YOUR LIMITATIONS
(include if Limitations are permanent or temporary):
I certify that the statements and information contained in this document and any attachments are true and complete to the best of my knowledge. I
hereby give permission to release any information contained in this request to authorized officials with a need to know.
PART III Certification of Requestor and/or Designated Appointee or Approving Official
11. REQUESTOR'S SIGNATURE:
12. ORGANIZATION/DEPARTMENT:
13. PHONE NUMBER:
14. DATE
:
(DDMMMYYYY)
15. SUPERVISOR'S SIGNATURE
15a. SUPERVISOR'S E-MAIL ADDRESS:
15b. PHONE NUMBER:
The signature above acknowledges receipt of this request for accommodation and all attachments if any.
SECNAV 12306/1 (Rev. 8-14)
Page 2 of 2
FOR OFFICIAL USE ONLY WHEN FILLED
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