Form SD Form 827 SD Form 827 Confirmation of Request for Reasonable Accommodation

CONFIRMATION OF REQUEST FOR REASONABLE ACCOMMODATION

OMB No.
OMB approval expires

The public reporting burden for this collection of information is estimated to average XXX per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria,VA 22350-3100
(XXXX-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a
currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE REASONABLE
ACCOMMODATION PROGRAM MANAGER.

PRIVACY ACT STATEMENT
AUTHORITY: 29 U.S.C. 791, 42 U.S.C. Chapter 126, 29 CFR Part 1630, E.O. 13163, E.O. 13164, and DoD Directive 1020.1.
PRINCIPAL PURPOSE(S): To document requests for reasonable accommodation(s) (regardless of type of accommodation) and the outcome of such
requests for employees of Washington Headquarters Services/Human Resources Directorate serviced components with known physical and mental
impairments and applicants for employment with Washington Headquarters Services/Human Resources Directorate serviced components. These records
are covered by SORN DWHS P49: http://dpclo.defense.gov/privacy/SORNs/component/osd/DWHSP49.html and Privacy Impact Assessment
http://www.whs.mil/EITSD/PrivacyImpactAssessments.cfm.
ROUTINE USE(S): The DoD "Blanket Routine Uses" found at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html apply to this collection.
DISCLOSURE: Voluntary. However, failure to provide sufficient information may delay or prevent an adequate basis to determine an appropriate
accommodation.

D R A F T

INSTRUCTIONS
This form should be completed whenever an employee or applicant requests an accommodation. For additional information or
assistance in completing this form, please call the WHS/LMER Reasonable Accommodation Program Manager (RAPM). Upon completion
of the form, please provide a copy to the deciding official, i.e., supervisor or other designee and a copy to the RAPM.
You may be asked to provide medical information in support of your accommodation request. Under the Rehabilitation Act, any medical
information obtained in connection with the reasonable accommodation process must be kept confidential and can only be disclosed to
and by authorized parties in accordance with the Privacy Act. All medical information obtained in connection with a request for reasonable
accommodation must be kept in files separate from the individual's personnel file and secured when not in use by the authorized parties.
This includes the fact that an accommodation has been requested or approved and information about functional limitations. It also means
that any employee who obtains or receives such information is strictly bound by these confidentiality requirements. For more information,
please see the text of the Privacy Act of 1974 (5 U.S.C. 552a), as amended, http://www.justice.gov/opcl/privstat.htm, and the OPM
regulations on the Employee Medical File Systems of Records, OPM GOVT-10.
1. APPLICANT OR EMPLOYEE
a. NAME (Last, First, Middle Initial)

b. TELEPHONE NUMBER
(Commercial or DSN)

c. EMPLOYEE'S ORGANIZATION
2. TODAY'S DATE (YYYYMMDD)

3. DATE OF REQUEST (YYYYMMDD)

4. ACCOMMODATION REQUESTED (Be as specific as possible, e.g., adaptive equipment, reader, interpreter.)

5. REASON FOR REQUEST

6. IF ACCOMMODATION IS TIME SENSITIVE, PLEASE EXPLAIN

Return form to Reasonable Accommodation Program Manager.
7. LOG NUMBER (Assigned by Reasonable Accommodation Program Manager)

SD FORM 827, 20130627 DRAFT

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