Information Collection

Disability Accommodation Request Form

IC 221228 under ICR 201604-3045-002 · OMB 3045-0179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3045-0179 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Disability Accommodation Request Form	Form
1 Disability Accommodation Request Form Disability Request Form_FINAL wPRA and Privacy.docx www.nationalservice.gov	Form

IC Title:

Disability Accommodation Request Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Disability Accommodation Request Form	Disability Request Form_FINAL wPRA and Privacy.docx	www.nationalservice.gov	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.