Form VA Form 0857A VA Form 0857A Written Confirmation of Request for Accommodation

OMB Number:
Respondent Burden: 10 minutes

WRITTEN CONFIRMATION OF REQUEST FOR ACCOMMODATION
An oral request from an applicant or employee is sufficient to begin the reasonable accommodation process. Completion of
this form is voluntary. However, individuals who have requested an accommodation are asked to fill out this form for
record-keeping purposes.
The Paperwork Reduction Act (PRA) of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the PRA. We cannot sponsor or require you to respond to a collection of information
unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will
average ten minutes including the time it will take to read the instructions, gather the necessary facts, and fill out the form.
Privacy Act Information: The information requested on this form is solicited under the authority of Executive Order 13164 that
requires the collection of data that will allow measurement and evaluation of the efficiency and appropriateness of the actions taken
by the Department of Veterans Affairs in processing accommodation requests. Information from the data collection will become part
of a System of Records that complies with the Privacy Act of 1974. This System of Records is identified as "Reasonable
Accommodation Processing Records" as set forth in the Compilation of Privacy Act issuances via online GPO access at
http://www.gpoaccess.gov/privacyact/index.html.
If you need assistance in completing this form, please contact the Human Resources office (for applicants) or the Local Reasonable
Accommodation Coordinator (for employees).
NAME OF APPLICANT OR EMPLOYEE

PHONE NUMBER OF APPLICANT OR DATE OF REQUEST
EMPLOYEE (Include Area Code)

EMAIL ADDRESS OF APPLICANT OR EMPLOYEE

OFFICE OF EMPLOYEE

SUPERVISOR'S NAME

SUPERVISOR'S PHONE NUMBER

TODAY'S DATE

ACCOMMODATION REQUESTED (Be as specific as possible)

REASON FOR REQUEST

IF ACCOMMODATION IS TIME SENSITIVE, PLEASE EXPLAIN BELOW

Applicants should give this form to the Human Resources Management (HRM) Officer.
Employees should give this form to their immediate supervisor or the LRAC.
NAME OF HRM OFFICER OR LRAC

VA FORM
JUL 2010

0857A

PHONE NUMBER OF HRM OFFICER OR LRAC LOG NUMBER ASSIGNED

This form should be retained separately from the employee's Official Personnel Folder.
Adobe LiveCycle Designer