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uNCLASSrFIgnmOn Onml

NATIONAL SECIJRITY AGENCY CENTRAL SECT]RITY SERVICB NSA/CSS POLICY 4-23

fa

Issue Date: 6 Marclil 2006 Revised:

'{,

(U) PROVISTON OF REASONABLE ACCOMMODATION

(u)
(U) This document

PURPOSE AND SCOPE-

establishes policy, describes procedures, and assigns responsibilities reasonable accommodatlon process, in accordance with the Federal for the NSA/CSS Rehabilitation Act of 1973 (Reference a), the Americans with Disabilities Act, as amended (Reference b) and Executive Order l3 | 64, "Requiring Federal Agencies to Establisl,r Procedures to Facilitate the Provision of Reasonable Accommodation" (Reference c).

(U) This policy applies to all civilian and military personnel throrrghout the NSA/CSS global enterprise, ineluding those serving a trial period and applicants for ernployrnent.

JOHN TAFLAN
Associate Director Human Resources

Endorsed by: Di,rector of Policy Encls:

(U) (U) (U) (U)

AnnexA-Procedures
Annex B - Agency-Wide Mandatory Accessibility Requirernents Annex C - Request for Accornrnodation Annex D - Internet Resource List

UNCLASSIFINN//FOR

OFFTC

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UNCLASSIFIEI}/IT'
Policy 4-23 DISTRIBUTION I PLUS: MC (5 stock copies) MC2 MA2 DC3l DC32t (VR) DC36 (Archives) Dated: 6 March
?,0Q6

(U) OPI: Disability Affairs, MC2

(963-7079s, 301-688-7779b).

(U) The cornpilation ofthe information contained in th.is docur.nent is LJNCLASSIFIED//FOR OFFICIAL USE ONLY. No seetion of this doc0n'rer'rt shall be released without approval from the Office of Policy and Records (DCa).

GD POLICY

(U) NSA/CSS shall provide r.oasonable accommodationw qualified tudividwls with disabilities during all stages of pre-ernploymnt and employment (References a and d).

l.

2. (U) NSA/CSS shallprovide access for qualified individuals with d'isabilities to NSA/CSS facilities, prcgrams, and electronic and information techrulogl (lT) systems, i'n accordance with the standardsfor accessibilityinSection 508 of Refernce a (AnnexB). In addition to the statutory rcquircrnents of Section 508, NSA/CSS shallvoluntarily comply with Section 508 provisions for all other electronic and IT systems, except as exempted for those that involve a compelling national security rnission requirement; those that involve titne+ritical national security operational requirements and will be used by fewer than 25 people; or those that preclude compliance for anonyrmity reasons. If an entity is using an exernption ftorn Section 508 cornpliance, the facts and circurnstances must be fully explained in the contracting
documents. Copies ofNSA/CSS reasonable accommodation procedrues shallbe made available on the NSAnet, in hardcopy format, and in fonnats readily accessible by ind'ividuals

3. (U)

with disabilities.

4. (U) NSA/CSS is not responsible for providing reasor,rable accommodations to independent contractors (lCs) except for physical modifications to NSA/CSS facilities (in accordance with Reference d). The lC's Conracting Offrcer's Technical Representative (COTR) should contact Disability Affairs (MC2) or the Office of Goneral Counsel (D2) for further guidance.
5. (U) NSA/CSS is not required to lower productivity standards, rcmove or change the essential job ftnctioru, or create a position as an accomnnodation for individuals with disabilities
(Reference b).

6. (U) NSA/CSS
hards h ip ( Reference b).

is not required to provide any accommodation that causes unduc

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---
Datod: 6 March 2006

UNCTASSIFIED/
Palicy

4-23
(U) RESPONSIBILTTIES

7. (U) Applican.ts, Employees and Integrces

shall:

a. (U) lnitiate requests for reasonable accommodation eithor personally or throulh representatives, The gai,ning organization wi'll csordinate with Disability Affairs (MC2)to provide the accomrlodation for detailoes.

b. (U) Cooperate with the accomr,nodation process by providing necessary dsoumentation, including rnedical inforrnation, as needed by NSA/CSS. Failure to cooperate (i.e., failure to provide documentation) eould result in denial ofthe request; and c.
requested.

(U)

Respond to an offer of accommodation wl,ten one has been offiered but not

8. (U) Supenisors/lVtranagers shall:

Consider and approve rcquests, unless the rcquest should be handled by Disabitity Affairs (MC2). If accom.rnodation is approved at the supervisory/ rnanageria.l level, the decision maker is responsible for detennining what accornrnodations are appropriate and effective;
a. b.

(U)

(U) Mainain (U)

confidentiality ofthe request;

Discuss a request with the ernployee no later than two business days frorn the date of the request. If the discussion does not occur within two business days, the supervisor/manager will docurnent the reason(s) for the delay;

c.

Discuss the need for an accornmodation with a qualified individual wifi disability, when it is observed that a disability rnay be linniting an employee's ability to perform the job at a fully successful level or when an accornrnodation could irnprove an employee's job performance or an applicant's ability to participate in the selection d.

(U)

prooess;

Im.rnediately contact Disabitity Affairs (MC2) for assistanee in determining the appropriate accommodation(s) if an ernployee cites a rnedical condition as the basiJfor a iong-term inability to perfonn oertain aspects of his/l,rer assigned duties or makes a rquest for an accom.rnodation where the disability is not obviotts;
e.

(U)

f. (U) Participate on any Reasonable Accomrnodation Fanel (RAP) convened regarding one of tteir employees, if requested to do so by Disability Affai,rs (MC2)-

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Policy 4-23

Dated: 6 March 2006

g. (U) Forward to Disa,bility Affairs (MC2) docurnentation (Anr..rex E and other appropriate medical documentation) reflecting all acconarnodation requests and decisions concerning the request;
h.

(U) If able to provide

the accom'rnodation:

l) (U) Act pronaptly to irnplernent the requested aocornrnodation. If the accommodation or the aocommodation deoision is delayed by more tharl 15 days frorn the date ofthe request, the supervisor/rnanager will document the reason(s)
why; and
Forward a cornpleted copy of the fon'n at Annex E of this policy, to Disability Affairs (MC2), as soon as possible, for record-keeping purposes.

'

2)

(U)

i. (U) If unable to provide the accomnrodation, refer the request to Disability Affairs (MC2) as soon as the decision is rnade that the accomrnodation cannot be . provided.

9. (U) Disability Affairs (MC2)

a.

shall:

(U)

Provide aecommodation, if possible;

Ovgrsee the processing of alt requests for accommodation including those requested itriougn the Leavi Bank ant Leave Sharing programs' Work-life Services and

b.(U)

Worker's Cornpensation prograrns;

c. (U) Maintain docurnentation and confidentiali'ty ofall accornrnodation rquests and accommodation decisions rnade by NSA/CSS personnel for the duration of the employee's tenure; d. (U) Convene a RAF to serve as the deoision-maker on matters that require input frorn several AgencY offices;
e. (U) Serve as the focal point for questions about reasonable accornmodation and rsourcs avaitable inside or outside NSA/CSS;

f. (U) Educate managers aRd:superuisors in processing accornrnodation requests;

g.

(U)

runug.it
h.

Facilitate the funding of acoommodations and provide supervisors and with information regarding resources and types of acconnmodation;

Work wi.th the Office of Recruifinent and Staffing as neoessary, to devise effective accommodation for applicants, if required;

(U)

i. (U) Coordinate with the gaining organization concerning detailees who request accommodation; and

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Policy 4-23

Dated: 6 March 2006

Make copies ofthe reasonable accommodation procedurcs.so that they are readily available to all NSA/CSS employees. Ch'ief Informa,tion Officer (DK) shal.l review and approve or disapprove requests for exemptions fror.n Section 508 eompliance (i.e., cornpelling national security r'nission requirements).
10.

j. (U)

(U) The

I 1. shall:

(U) Occ.upational Health, Environmental and Safety Services (ME) personnel

a.

Review nredical documentation, when requested, and advise Disability Affairs (MC2) regarding whether or not the individual has a disability;

(U)

on all requests for medical infonnation and assist with erafting rquests for rnedical information to ensurc that only information relevant to the clairned disability is requested or d.isclosed; b.

(U) Advise MC2

information atready in Occupational Health, Environmental, and Safety Services (ME)'s files, which perta.ins exclusively to the clai.rned disability accornrnodation request, so that MC2 may determ,ine whether the employee has a covered disability;

c.

(U)

Frovide MC2 or the decision maker with a sumrnary of the medical

d.(U) Make every reasonable effort to assist employees who do not meet the definition of "qualified individual with a disability" to be fully productive, preserve their health, and prevent exacerbation of illnesJinjury and disability;
e.

(U)

Farticipate in the deliberations ofthe RAP, as required; and

f. (U) Refer requests for accommodation ts the Office o'f Disability Affairs.
12.

(U) Ofiice of the General Counsel @2) shalt:

a.

Provide advice to the decision maker, Disability Affairs (MC2), or any otherNSA/CSS official with regard to the reasonable accomrnodation process; and

(U)

Provide.advice to the R,AP (not to include the approval or d'isapproval grant ing accomrnodations).
b.

(U)

of

13.

(U) Facilities
a. b.

Services (LF) penson'nel shall:

(U)

Assist in providing reasonable accommodations, as necessaty, and Participate in the deliberations of the RAP, as requ'iretl.

(u)

UNCLASSIFIED//FOR

onrrlel*l

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UNCLASSIFIED//T'O
Policy 4-23
14.

6 March 2006
shall:

(U) Ollice of Recruitment end Staffing $MB)

a.

(U)

Coord,i'nate appl,icant rqucsts for accomrnodation witt'r Disability Affa'irs

(MC2);
b. (U) Advise applicants of the essential job functions of a position. (Recruitment and Staffing personnol rnay ask the applicant hsw he/sl're will meet the requirements of the job); and c. (U) Conduct searches fbr vacancies for curent ernployees with disabilities who must be reassigned.
15.

(U) Oflice of Equal Employment Opportunity @6) shall:.

a.

(U) (U)

Refer requests for reasonable accornmodation to Disability Affa'irs (MC2)

for processing; and

Frocess EEO connplaints regarding denied reasonable acoomrnodation requests in accordance with Ref,erences e and f.

b.

(u) REFERENCES
16.

(U)

References:

a.

(U) Title 29 United States Code Section

as amended.

791, "The Federal Rehabilitation Act

of 1973,"
b.

(U)

The Americans with Disabilities Act of 1990.

c. (U) Executive Order l3l64,"Requiring Fedoral Agencies to Establish Procedures to Facilitate the Provision of Rsasonable Accommodation," dated July 26, 2000.

d.(u) Title42 united states code,

Barriers Act."
e.

section 415l et. seq., "Ttre Architectr,rral

(U) PMM Chapter

365, "Equal Employrnent Opportunity."

.

f. (U) 29 Code of Federal Regulations, Sections 1614, "Federa,l Sector Equal

Employment Opportunity" and 1630, "Regulations to Implen.lent the Equal Employrnent Provisions of the Americans witt'l Disabilities Act."
g.

(U)

PMM Chapter 352, Section 6'a (lg) "Basic Pay Rates."

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UNCLASSIFIEI}//FOR O
(U) AnNEx A

(u) PROCEDIIRES
l. (U) Initiating the Reasona,ble A,ccominoilation
Process:

*"o

a" (U) The reasonabte accommodation process begins when a requestfor *ofution (hereafter "requesf) is made by an ermployee or applicant. To begin the process, the individual or hiVher representativ must advise an Ageney oficialthat an

idjustment or change at work is needed for a rcason related to a rnedical eondition. When a reprcsentative makes a request on behalf of an individual, the Agency official

willeonfinn with the individua,l that the accornmodation

b.

is desired.

The initial request rnay be rnade orally or in writing. Individuals are not rcquired to mention the Rehabilitation Act, the ADA, or the phrase "reasonable accornmodation" in requesting an aocommodation. Furthermore, an individr'ral with a disability is not requ.ired to rmake a request for a reasonable accommodation at any particutar time. The Agenoy official rnay ask for the r,equest in writing for reeordn'Request for Accomrnodation'), bUt rnay not delay in keeping purposes (Annex E: initiating the reasonable accornmodation prooess.

(U)

c. (U) Once the accornmodation is approved, the anployee is not required to rnake another request. In such situations, the employee may obtain the accommodation by notice to the appropriate individual or offico, e.g., for sign language

interprcter services.
d. (U) Managers generally may not ask an applicant whether he/she needs a reasonable accommodation for the job. The hiring rnaRager rnay speciff the essential functions and ask the applicant how he/she will meet the requirernents of the job.

job

disability, the manager should contact Disability Affairs (MC2) for guidance, if necessary. MC2 personnel will work with the manager and tl're applicant to devise an effective accommodation strategy.
2. (U) Prccessing the Request:

e.

(U) lf the appticalat

has an obvious disability or voluntarily discloses a

(U) Throughout this interactive process, those responsible for accomrnodation decisions will communicate with the requestors to gain a clear unders0anding of the needs
a.

'possible

involved. The employee requesting the accommodation should participate to the extent in helping toidentiff an effective accornmodation. This will help to ensure that the most effective accommodatisn can be provided.

Annex A to Policy 4-23 Dated: 6 March 2006

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'SE

UNCLASSIFIED//FOR OFFICIAT
b.(U)

ONI#

When a disability and/or need for accomrnodation is not obvious, the request shoutd be referred to Disability Affairs (MC2). MC2 will advise whether medical information is necessary to support the request, whether the medical infonnatiotl provided by the requestor is insufficient, or if the Agency already has all the necessary medical infonmation to process tl,re request. c. (U) If the supervisor or other individual receives a request wlaere the need for the accornmodation isobvious, but he/she is unable to impler'nent the request, he/she will ref,er the rcquest to Disability Affairs (MC2) for resolution, either to suggest and implernent an alternate but effective accommodation or to determine if any accommodation oan be rnade. Under these circumstances, MC2 will be the firaal decision maker. MC2 may use the procedures outlined in this Annex to resolve these issues. d. (U) All decisions kept confidential.

will

be made on acase-by-case basis and all req.uests

will

be

e.(U) The manager's response to an employee's request for a medically based adjustment to his or her ernployment situation may vary depending on the nature of the medical condition. lf an ernployee cites a rnedical condition as the basis for a long-term inability to perform certain aspects of his/l,rer assigned duties, then the rnanager shou"ld immediately contact MC2 for assistance in deten'nining the appropriate accommodation(s).
f. (U) NSA/CSS will begin processing the request within two wor{<ing days o,f receipt. Special circumstances may dictate that NSA/CSS begin processing a request immediately. If a supervisor fails to respond to a request with an initial contact with,in two business days, the enrployee should contact a second-line supervisor, or Disability Affairs (MC2).
have up to 15 working days (absent extenuating circumstances) to grant or deny requests. When possible, this tirne frame will include delivery of services or equipment. If the decision or accommodation can be provided in less than l5 days, the decision rnaker should attempt to do so. Each decision maker is required to have a back-up; therefore, the absence of a decision rnaker is not a valid reason for suspending or extending the time frarne for providing acconmodation. If reasonable accornr.nodation cannot be delivered within l5 days, MC2 rnust investigate whether there are temporary rneasures to assist the individual with a disability.

g.(U) NSA/CSS will

(U) The manager r.rust notifi the individual of a decision withi'n the designated time limiti. ifa request fu made to a manager, but referred to and handled by Disability Affairs (MC2), MC2 will process the request and notiff the individual of a decision
h.

within the designated time limits.

Annex A to Policy 4-23 Dated: 6 March 2006

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UNCTASSIFIED/
i. (U) Where there are extenuating circurnstances, (e.9. delays in the recei,pt of, medical documentation, equ.iprnent is backordered, etc.) the decision rnaker(s) will notiff the requestor, in writing, of the reason for the delay and keep him/her inforrned of the expected date that the request will be ptocessed.

j. (U)

The supervisor or other individual receiving the request shall ask for the

req.uest in writing (using the fonn in Annex E) for racord-keepir'rg purposes and sharll forward a copy ofthe docurnont to Disability Affairs (MC2), but may not delay processing the request while awaiting a writter'r rqust.

k. (U) Managers who reeeive or pJocess requests should discuss the request with the omployee as soon as practicable, but may not question ernployees about their rnedical histories or rely on assurnptions about an irnpairrnent to determine if an employee raray need an accommodation. l. (U) Requestors of reasonable acooinrnodation must provide appropriate medical information related to the disability and proposed accomnodation where the disability or need for accorrmodation is not obvious. This includes sufficier,rt information for the Agency to detennine if the ernployee or applicant is a qualified individual with a disability under Reference a. The Agency rnay request relevant supplernental medical infonnation. If the infonnation subrnitted does not clearly explain the nature of the disability or substantiate the need for reasonable accom'rnodation or if the medical information subm'itted is not sufficient, NSA/CSS may also require that a physician of NSA/CSS's choosing exarnine the requesting individual at the expense of NSA/CSS. m. (U) When necessary, Disability,Affairs (MC2) will consr*it with a health care professional in Occupational Health, Environmental and Safety Services (ME) to ensure that only information relevant to the specified aecomr,nodation is requested.
n. (U) lfthe information provided by the heal'th car or other appropriate professional is insufficient to detemline whether an aocom,modation is appropriate, Disability Affairs (MC2), with guidance from Oceupational, Health, Environmental and Safety Services (ME), may request further relevant medical information. MC2 will explain in writing to tlre employee seeking the accomrnodation why the infonnation provided is insufficient, what additional information is needed, and why it is necessary for a detennination of the reasonable accomrnodation rquest. Ernployees will be given the option to sign a medical release form, so that OHESS medical professionals ntay ask questions of the requestor's health care professional to clariff rnedical information and to supplement i nadequate docurnentation.

Annex A to Policy 4-23 Dated: 6 March 2006 A-3

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UNCLASSIFIED//T'On

onFICffi

o. (U) If a disability/accornmodation determination involves a non-obvious disability, a request for accommodation that impacts upon several Agency offices, or odrer circumstances that Disability Affairs (MC2) deerns appropriate, MC2 rnay convene a tteasonable dccornrnodation Panel (RAP) composed of appropriate representatives. The RAP should be convened within a reasonable time of MC2's r'eceipt of an accommodation request, not morc than 15 business days, or as soon thereafter as all relevant inedical and other information is obtained. MC2, considering the RAP's input,

will respond in writing to the requestor Ro later than 7 days after the RAF's deliberations
are cornpleted. Because Reference a requires that al.l rnedical infonnation be kept confidentialo any medical information obtained in conneetion wittl a rquest will be kept in files sparate from the requestor's personnel file, and will be shared only with

individuals who have an ofricial need-to-kttow.

offered, the Agency may determine if the ernployee is or is not qualified to remain in the job. If the accommodation is necessary to Eliminate a direct threat to hiVher health or well-being or that of fellow employees, or is needed to perfonn the essential functions ofthe position, NSA/CSS may ref,er the matter to Ernployee Relations.
p.

(U) If the rcquestor refuses to aceept the accommodation

When a decision rnaker denies a request sr offers an alternative accommodation, the deoision must be provided to the employee in writing and fonvarded to Disability Affairs (MC2). Requests may be denied underthe following circumstances:
3. a.

(U) Denial of a Request:

(U) The decision

is rnade that the requestor is not a qualified individual with a

disability under Reference a.

b. (U) The decision maker determines that the requested accommodation would cause an undue hardship for NSA/CSS. The decision maker must cooldinate any decision of undue hardship with Disabil.ity Affairs (MC2) prior to making this determination. Determinations of undue hardship rnust be based on an individualized assessment of the ernployee's current circurnstances that show a specific accommodatioll would cause significant detay or expense. A finding of undue hardsh.ip shall be based on

the following:

l) (U)
2)
3) 4)

The natilre and cost of the accornrnodation needed; The financial rcsources ofthe Agency as a whole; The impact of the accommodation on the Agency; and/or

(U) (U) (U)

The fact that provision sf the accommodation would be unduly disruptive to other employees' ability to work.

Annex A to PolicY 4-23 Dated: 6 March 2006

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c. (U) If Disability Affains (MC2) or aRy other Agency official denies an ernployee's request for accomrnodation, the ernployee wi:ll be advised in writing of the specific reasons for the denial, of hiVher right to file an Equal Ernployrnent Opportunity (EEO) eornplaint (Reference e) wittrin 45.days ofthe discriminatory event ("go EEO") and/or use ofthe dispute resolution process for reconsidtfration of the denial ("go resol,ution")

4. (U) Reassignment Reassignment is an accornrnodation of last resoft. Qualified individuals with disabilities who canRot be accomrRodated in their current position will be considered for reassignment to a vacant position as an acconrlrnodation, as follows:
a. (U) Disabit:ity Af-fairs (MC2) will rneet with the ernptoyee in need of reassignnnent to deter.rnine skills and background of the individual and request an up-todate resurne.

b. (U) Disability Affa,irs (MC2) will noti'fy the Staffing Divisisn (MBl), via ernail, of the need for reassignrnent and provide a copy ofthe individual's r'surne. c. (U) The Staffrng Division (Mtsl) will review all vacant positions at NSA/CSS, well as those that are expected to become vacant witl,rin l0 days and that managernent as plans to fill, to find a position the individual is qualified to fill. The search will first focus on positions that are equivalent to tt're employee's current position in terms of grade or pay schedule, work role, and skill comrnunity. Ifthere is no vacant equivalent position, the Staffing Division (MBl) will identifo positions in a different work role, pay schedule, or skill community at the onnployee's current grade level. Ifthere is ns vacant position at the employee's current grade, the Staffir'rg Division (MBl) will search for vacancies at a lower grade for which the individual is qualified. The Staffing Division (MBl) will notif, Disability Afftirs (MC2), via email, within three working days of the request of any available Agency position(s) that match(es) the ernployee's qual ifi cations. d.
e. (U) Disability Affairs (MC2) will rneet with the POC for the position(s) to explain the Reasonable Accommodation Policy and the reassigninent process. The POC will be advised that the Agoncy will be placing a I'lold on the position with the possibi'lity of directing an ernployee into that position as an accommodation.

(U)

'

f. (U) If more than one vacancy is identified for wh'ich tlre individual is qualified, the individual will iraterview the prospective offices to determine tt're position to which he/she would like to be reassigned.
g. (U) Any employee assigned to a lower graded position as an accommodation be entitled to grade and pay retentiqn in accordance with Reference g.

will

Annex A to Policy 4'23 Datedi 6 March 2006

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h. (U) An employee in a probationary status is eligible for reassigr'lment provided that helshe was able to perfonn the essential firnctions of hiVher position with or without reasonable accomrnodation before the need for reassigrararent arose.

i. (U) No employee will be required to cornpete for a reassignrnent as an accommodation. The employee need not be the best qua.lified for the position; he/sho needs only to have the requisite qualifications for the position as evidenced by comparing his/her resume against the vacancy announcement, work role.description, skill community requirements, and job description.

j. (U) If the employee chooses to accept a positior,r outside the loca.l eornmuting area, Disability Affairs (MC2) shall forward the reassignment action to Global PCS services for a determination as to whether the Agency will pay the employee's relocation eosts.
k. (U) If the employee refuses to accept the position identified, he/she will be subject to procssses administered by Employee Relations, including involuntary separation in acoordance with Reference h. l. (U) Supervisor haining on the Reasonable Accor.nmodation Process is available through the National Cryptologic School.

Annex A to Policy 4-23 Dated: 6 March 2A06

A-6

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(rr) Ar\rNEx B

(u)

NsA/css-wxDE MANDATORY ACCESSIBTLTTY REQUXREMENTS

.A,ll NSA/CSS owned or oceupiedlleased buildings r,r.rust coneply with the accessibility provisions of Seotion 508 of the Federal Rehabilitation Aot as ar'nended. Any contracts established for the use of extemal facilities (for example, hotels f,or conf,erences or training) must reflect the obligation that the facilities be accessible to people with disabilities.

l. (U)

2. (U) Pursuant to Section 508, elechonie and infonnation technology developed, proeured, rnaintained, or used by NSA/CSS or an NSA/CSS contactor to perforrn routine administrative and business applications must comply with regulatory accessibility requirernents for individua,ls with disabilities. 3.

(U)

Regardless of fonarat, all unclassified vidoo and rlrultirnedia productions

including videcitapes, televised live broadcasts of intemalNSA/CSS television feeds, and rebroadcasts of live telwision feeds - that cona.in speech or sther audio necessary to understand the content shall be captioned or taped simultaneously with a qualified si.gnlanguage interpreter or provided in an alternate format (i.e., transcript).
4. (LttTFOttO) Offices that rrreed to convert non-captioned videotapes to open or closed caption may contact Disability Affairs (MC2) for referral. Requests for interpreter services may be submitted to Disability Affairs (MC2) Interprcting Staff, via e-rnail (DL TER.PS@nsa) or

TTY/telephone at

301

-688-7636(b/963-7052(s).

Annex B to Policy 4-23 Dated: 6 March 2006

B-l

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UNCLASSIFIEDIMOR OTTII*L USE

(u) ANNEX c
(tr) REQUEST FOR ACCOMT|,IODATION
(Please print all entries clearly; classifu appropriately)

OffiY

l. Narne ofApplicant or Ernployee Requesting Accommodation:

2. Today's Date:

3.

Date of Request:
:

4. Appl i cant' s/Emp loyee' s Contact Informat ion

Secure Phone:

Non-Secur Phone:

Agency ernail address (for employee): Internet email address (for applicant, if available):

Applicant's phone number:

5. Employee's Organization, Building, Roorn Number, Suite Nunaber and Supervisor (with emai t/phone contact inforrnati on) :

6. Reason for Request, Other Cornments (attach other sheets as necessary):

7. Accommodation Requested: (Be as specific as possible, e.g., adaptive e,quiprrr.rent,.interpreter,

etc.)

8.

Employee/ Applicant's Signature:

Annex C to Policy 4-23 Dated: 6 March 2006

c-l UNCLASSIF'IED/IFOR OFFTEI^L USE

ONI

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UNCLASSIFIED//FOR
Agency's Official's Printed Name, Signature
Printed Name:
ar'rd Date (Con.finning the request):

Signature:

Date:

9. Disability Determination (For Disability Affairs (MC2) use only):

Yes

No

Determination not made

10, Accom'modation Determination (Attach other sheets as necessary):

(Circle One):

Approved

Den'ied

l. Date Request lrnplernented:

Follow-up dtre within 30 days of

I2.

implementation:

Date Completed:

Distribution:
Employee Supervisor

MC2

Annex C to Policy 4-23 Dated: 6 March 2006

UNCLASSIFIED//FOR O

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USE

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(u) ANr\rExI)
(u) TNTERNET RESOTJRCE [rST

l. (U) Job'Accommodation Network

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an

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;ruterfEleotnrnics
www.tdcalr.osd
.

Accornrnodation Fnograrn (CAP):

nl

il/cap

3. (U) EEOC Rcasonable Accsmmodation Guidance:

gnilw.eeoq.eov/policy/d,p-"cg/accommod4tion.htrnl

Annex D to Polioy 4-23 Dmed: 6 March 2006

D-l TINCT,ASSIF'IED//F'OR OT'F'I

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