Form Section 508 Form Section 508 Form Reporting Form for Section 508 Technology Accessibility

REPORTING FORM FOR SECTION 508
TECHNOLOGY ACCESSIBILITY ISSUES
PURPOSE: The purpose of this form is to assist you with reporting a technology accessibility issue.
You should use this form if you are an individual with a disability, and because of that disability, you
are having difficulty accessing electronic and information technology provided by the Social Security
Administration (SSA).
SSA POLICY: Federal law and SSA policy require that when we develop, procure, maintain, or use
electronic and information technology, we ensure that individuals with disabilities who are members of
the public have access to and use of information and data that is comparable to access available to
members of the public who are not disabled, unless this would impose an undue burden on the
agency. For more information go to http://www.ssa.gov/accessibility/508_overview.html
SECTION 508 STANDARDS: Section 508 requires electronic and information technology procured
by a federal agency on or after June 21, 2001, comply with standards issued by the Architectural and
Transportation Barriers Compliance Board. For more information about the Section 508 law,
application, exceptions, and standards, go to http://section508.gov. Electronic and information
technology includes information technology and any equipment or interconnected system or
subsystem of equipment that is used in the creation, conversion, or duplication of data or information.
HOW AND WHERE TO FILE:
FORMAL COMPLAINTS
To file a formal complaint alleging that SSA’s electronic and information technology does not comply
with Section 508 of the Rehabilitation Act, please complete (1) this form and (2) the Program
Discrimination Complaint Form, SSA-437-BK, which is available on our website at
http://www.socialsecurity.gov/online/ssa-437.pdf.
You are not required to use either form. You may write a letter instead, but the letter must contain all
of the same information requested by these forms.
Please mail, fax, or email a completed, signed, and dated copy of your complaint to us:
Mailing Address:

Social Security Administration
Program Discrimination Complaint Adjudication Office
Room 617 Altmeyer Building
6401 Security Boulevard
Baltimore, MD 21235

Fax Number:

(410) 597-0507

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Email Address:

[email protected]

Please keep in mind that sending any sensitive or protected information to us in an unsecured email
presents a risk of disclosure to, or interception by, unintended third parties. Your use of email to
communicate sensitive, personally identifiable information to us indicates that you acknowledge and
accept the possible risks associated with such communication. Please consider communicating any
sensitive information by telephone, fax or mail.
If you have any questions about the complaint process, or if you have questions about a complaint
you have already filed, you may use the above contact information to write, fax, or email us, or you
may call us toll-free at (866) 574-0374.
REPORTS OF A TECHNOLOGY ACCESSIBILITY ISSUE
If you identify a technology accessibility issue but do not want to file a formal discrimination complaint,
you can use this form to report the issue.
Please mail, fax, or email a completed, signed, and dated copy of the form to us:
Mailing Address:

Social Security Administration
Office of Civil Rights and Equal Opportunity
Social Security Administration
6401 Security Boulevard
Baltimore, MD 21235

Fax number:

(410) 966-0941

Email address:

[email protected].

Please keep in mind that sending any sensitive or protected information to us in an unsecured email
presents a risk of disclosure to, or interception by, unintended third parties. Your use of email to
communicate sensitive, personally identifiable information to us indicates that you acknowledge and
accept the possible risks associated with such communication. Please consider communicating any
sensitive information by telephone, fax or mail.
If you have any questions about how to report a technology accessibility issue, or if you have
questions about a technology accessibility issue you have already reported, you may use the above
contact information to write, fax, or email us, or you may call us toll-free at (844) 881-9061 Monday
through Friday, 8:00am – 4:00pm Eastern Time (except Federal Holidays).

AFTER YOU HAVE COMPLETED THIS FORM, YOU MAY REMOVE THESE INSTRUCTIONS AND
KEEP THEM FOR YOUR RECORDS.

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Technology Accessibility Issue Reporting Form
If you are reporting a technology accessibility issue, please complete all questions below. If you
are reporting a formal complaint (which requires completion of the Program Discrimination
Complaint Form, SSA-437-BK, in addition to this form), please skip to question 3.
1. Please identify the person who was unable to access electronic and information technology
provided by the Social Security Administration (SSA):
Name
Address
City
State
Zip
Daytime phone number
Email address (optional)
Social Security Number
2. If you are filing this request on behalf of a person seeking assistance, provide the following
information about yourself:
Name
Address
City
State
Zip Code
Daytime phone number
Email address (optional)
Relationship to the person seeking assistance.

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3. Are you a current SSA employee or contractor? [In questions 3 through the end of this form,
“you” and “your” refer to the person requesting assistance.]
 Yes
 No
4. Describe the nature of your disability and how your disability makes the information and data
inaccessible to you.
5. Describe the problem you are having accessing and using information and data through SSA’s
electronic and information technology. Describe in detail the steps you take before you
encounter the problem, and exactly what happens or does not happen when you experience
the problem. Please be as specific as you can (use additional pages as necessary) and
provide any documentation you believe will help us understand the problem.
6. What is the specific information or data you are not able to access or use?
7. How was SSA trying to provide this information or data to you (check any that are appropriate):
 Public website (specify web address)
 Internal website (specify web address)
 Electronic communication (specify type of electronic communication)
 Electronic document or form (specify document and how obtained)
 Multimedia – for example: video, recorded or live events, webinar, audio file (specify
name and description of media and how obtained)
 Kiosk (specify location)
 Office equipment (specify equipment type and location)
 Telephone equipment (specify equipment type and location)
 Video equipment (specify equipment type and location)
 Storage Media - for example, a data CD) (specify storage medium type and how
obtained)
 Other (specify)
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8. Describe any personal equipment, operating systems, software (e.g., browser), and any
assistive technologies you used to access this information or data.
Computer Name and Product #
Operating System (example: Windows version 8.1)
Browser and version # (example: Internet Explorer version 11)
Assistive Technology (example: JAWS version 12)
9. When did you become aware that you were not able to access or use this information or data
through SSA’s electronic and information technology?
10. If you have ever been able to access this information or data through SSA’s electronic and
information technology before, provide the date(s) you were able to access it and describe how
you accessed it.

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Privacy Act Statement Collection and Use of Personal Information
Complainants (including individuals who informally report a technology accessibility issue) and
individuals who cooperate in an investigation by the Social Security Administration (SSA) into an
alleged violation of Section 508 of the Rehabilitation Act are afforded certain rights and protections.
This brief description will provide you with an overview of these rights and protections.
SSA may collect information concerning formal and informal complaints of inaccessible electronic and
information and technology pursuant to 5 U.S.C. § 301, 29 U.S.C. §§ 794(a), 794(d), 42 U.S.C. §
902(a)(5), 45 C.F.R. Part 85, 20 C.F.R. § 405.30, and Executive Orders 13160 and 13166. The
responses you provide will be used to make a decision on how we will process your complaint. Your
responses are voluntary; however, we may be unable to proceed with processing your complaint if
you choose not to provide the requested information. You do not have to use this form. You may also
write a letter that includes all of the requested information.
We rarely use the information you provide for any purpose other than for processing your complaint.
We may, however, disclose the information in accordance with routine uses of the Privacy Act (5
U.S.C. § 552a(b)), which include, but are not limited to, the following:
1. To a congressional office on behalf of an individual in response to an inquiry made at the
request of the individual who is the subject of the record;
2. To the Office of the President for the purpose of responding to an individual pursuant to an
inquiry from that individual or from an third party on the individual;
3. To another Federal agency or to a court or third party in litigation when the Government is a
party to a suit before the court;
4. To a Federal, State, or local agency for law enforcement purposes concerning a violation of
law;
5. To the Department of Justice, the Equal Employment Opportunity Commission, or other
Federal and State agencies when necessary for the administration or enforcement of civil
rights laws or regulations.
Complaint records are exempted as investigatory material, compiled for law enforcement purposes,
from certain Privacy Act access, amendment, correction, and notification requirements (5 U.S.C. §
552a(k)(2)). However, a complainant or any member of the public may request release of this
information under the provisions of the Freedom of Information Act (5 U.S.C. § 552).

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A complete list of routine uses for this information is contained in our System of Records Notice 600275, Civil Rights Complaints Filed by Members of the Public. Additional information regarding this
form and our other system of records notices and Social Security programs are available from our
Internet website at www.socialsecurity.gov or at your local Social Security office.
The Paperwork Reduction Act -This information collection meets the requirements of 44 U.S.C.
§3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer
these questions unless we display a valid Office of Management and Budget control number. We
estimate that it will take about 1 hour to read the instructions, gather the facts, and answer the
questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address;
do not send the complaint form to this address.

AFTER COMPLETING THIS FORM, REMOVE THE LAST TWO PAGES AND KEEP THEM FOR
YOUR RECORDS.

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