Reasonable Accommodation Requests, 3060-XXXX FCC Form 5626 (Reasonable Accommodation Request Form) August 2017
and FCC Form 5627 (Medical Consent Form)
Supporting Statement
A. Justification
Executive Order 13164, Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommodation (Jul 26, 2000), requires each Federal agency to establish effective written procedures for processing requests for reasonable accommodation by employees and applicants with disabilities. Moreover, Executive Order 13164 requires Federal Agencies to track the processing of requests and maintain the confidentiality of medical information. In order to process, track, and maintain the confidentiality of reasonable accommodation requests, the Office of Workplace Diversity (OWD) of the Federal Communications Commission (FCC or Commission) collects this information on FCC Form 5626 (Reasonable Accommodation Request Form), and FCC Form 5627 (Medical Consent Form) (Generally, Reasonable Accommodation Forms).
The Commission is requesting the Office of Management and Budget (OMB) approval of this new information collection in order to obtain the full three-year clearance.
Records may include information about respondents, e.g., personally identifiable information or PII, and the use(s) and disclosure of this information is governed by the requirements of a system of records notice or “SORN,” FCC/OWD-1, “Reasonable Accommodation Requests under the Rehabilitation Act of 1973.” There are no additional impacts under the Privacy Act.
Statutory authority for this information collection is contained in Rehabilitation Act of 1973, 29 U.S.C. § 12101 et seq.; see also 29 C.F.R. Part 1630; Establishing Procedures to Facilitate the Provision of Reasonable Accommodation; EEOC, Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act, 29 C.F.R. Part 1615.
This information will be used by the OWD to process, track, and maintain the confidentiality of reasonable accommodation requests.
Respondents will have the ability to file and gain access to this information both electronically and through paper files. Initially, the information will be maintained in a paper filing system. Over the next several years, the FCC will transition to an online filing and reporting system. By using the electronic submission portal, requesters will have immediate confirmation of the date their materials are received and will have 24-hour, 7 day access to the electronic portal to upload and download documentation and view the status of their requests.
However, in recognition that some respondents cannot file electronically, the OWD will retain the ability for respondents to file complaints manually. This information will be uploaded into the Online Request portal by OWD personnel.
There is minimal duplication of the information in the Reasonable Accommodation Forms. Duplicative information amongst the forms pertains to the Requester’s name and the unique file number for each request.
The collection of this information will not have significant economic impacts on small businesses, organizations or other small entities. In order to file a Reasonable Accommodation request, requesters must provide certain information to allow the FCC’s Office of Workplace Diversity to determine that the employee or applicant satisfies the requirements of the Rehabilitation Act of 1973 for filing a request.
The information must be collected in order to comply with the Rehabilitation Act of 1973, 29 CFR Part 1630, and EEOC Policy Guidance on Executive Order 13164: Establishing Procedures to Facilitate the Provision of Reasonable Accommodation.
There are no special circumstances associated with this information collection.
The FCC solicited public comments on the Paperwork Reduction Action information collection requirements on June 12, 2017 at 82 Fed.Reg. 26926. No comments were received from public.
There will be no payments or gifts to respondents in connection with this information collection.
Confidentiality of information will be provided in accordance with the Privacy Act.
The information requested in the Reasonable Accommodation Forms assists requesters to provide information to ascertain if the requesters qualify for an accommodation to perform the essential functions of their duties. Specifically, the FCC Form 5626(Reasonable Accommodation Request Form) provides information regarding the requester’s condition, and how the condition affects the requester’s major life activities and job functions or employment benefits, while the FCC Form 5627(Medical Consent Form) allows for the collection of medical information in support of the request.
Although the provision of this information is voluntary, if the requester fails to submit the information the OWD may be unable to determine if the requester is a qualified employee or applicant who satisfies the requirements to obtain an accommodation in accordance with the Rehabilitation Act of 1973.
The average number of Reasonable Accommodations requests filed for Fiscal Years 2015 and 2016 was 52. Typically, respondents complete the forms themselves. However, there is a significant increase in the number of filings for FY 2017. With a little over 58% of the fiscal year completed, the OWD has already received 51 requests. Accordingly, the projection for FY 2017 is 75. The Commission estimates that 60 respondents will file a Reasonable Accommodation request annually and that the average burden per response is 5 hours. This response time includes medical appointments, obtaining documentation from medical personnel, preparing and reviewing the request. The total annual burden hours for the 60 requests is 300 hours. The Commission estimates that 99% (59) of the respondents will complete and file the form themselves without assistance. The Commission estimates the average per response for respondents to complete the form without assistance is approximately 5 hours. The Commission estimates that 1% (1) of the respondents will complete and file the form themselves after consultation with an attorney. The Commission estimates the average per response for respondents to complete the form including consultation with an attorney is approximately 8 hours. The Commission estimates that 2.5 hours is allotted to the consultation with the attorney for the Reasonable Accommodation form.
Reasonable Accommodation Request Form |
||||
Fiscal Year |
Annual Filings (Responses) |
Frequency of Response |
Average Response Time (Hours) |
Annual Burden Hours |
2015 |
51 |
1 |
5 |
255 |
2015 |
1 |
1 |
8 |
8 |
2016 |
51 |
1 |
5 |
255 |
2016 |
1 |
1 |
8 |
8 |
2017 |
74 |
1 |
5 |
370 |
2017 |
1 |
1 |
8 |
8 |
Total |
179 |
|
6 |
904 |
Average |
59.67 rounded up to 60 |
|
|
301.33 rounded up to 302 |
Annual Totals |
60 requests |
|
|
302 hours |
Total Respondents: 60 requesters
Total Annual Responses: 60 requests
Total Annual Burden Hours: 302 hours
The Medical Consent form is a new form. Respondents will submit this form with the Reasonable Accommodation Form. Thus, similarly, for the Reasonable Accommodation form, most respondents will complete the forms themselves. The OWD estimates the average number of annual filings will be 60 and the total annual burden hours for the 60 requests is 10 hours. The average burden per response is 0.16 hours. This response time includes reading and signing the form. The Commission estimates that 99% (59) of the respondents will complete and file the form themselves without assistance. The Commission estimates the average per response for respondents to complete the form without assistance is approximately 0.16 hours. The Commission estimates that 1% (1) of the respondents will complete and file the form themselves after consultation with an attorney. The Commission estimates that 0.5 hours is allotted to the consultation with the attorney for the Medical Consent form.
Medical Consent Form |
||||
Fiscal Year |
Annual Filings (Responses) |
Frequency of Response |
Average Response Time (Hours) |
Annual Burden Hours |
2015 |
51 |
1 |
0.16 |
8.16 |
2015 |
1 |
1 |
0.50 |
0.50 |
2016 |
51 |
1 |
0.16 |
8.16 |
2016 |
1 |
1 |
0.50 |
0.50 |
2017 |
74 |
1 |
0.16 |
11.84 |
2017 |
1 |
1 |
0.50 |
0.50 |
Total |
179 |
|
0.16 |
29.66 |
Average |
59.67 rounded up to 60 |
|
|
9.89 up rounded to 10 |
Annual Total |
60 requests |
|
|
10 |
Total Respondents: 60 requesters
Total Annual Responses: 60 requests
Total Annual Burden Hours: 10 hours
Cumulative Total for FCC Form 5626 (Reasonable Accommodation Request Form) and FCC Form 5627 (Medical Consent Form)
Total Respondents: 60 Reasonable Accommodation Request + 60 Medical Consent Form = 120 forms / 2 forms per respondent = 60 Respondents
Total Annual Responses: 60 Reasonable Accommodation Request + 60 Medical Consent Form = 120 forms
Total Annual Burden Hours: 302 hours + 10 hours = 312 hours
The remaining 1% (1) of respondents will hire a law firm or outside agency to assist the Respondent with completing and filing the Reasonable Accommodation forms. The typical fee is $300 an hour for representation, plus the cost of supplies (envelopes, postage, cover letter, etc.). For those respondents hiring a law firm, we estimate a burden of approximately 10 (9.89 rounded up) hours for the attorney to discuss the request with the respondent, and provide legal advice to the Respondent to complete and file the forms, and the Respondent to prepare and file the forms.. The Commission estimates that 3 hours is spent in the consultation with the attorney (2.5 hours for the Reasonable Accommodation form and 0.5 hours for the Medical Consent form). Thus, the Commission estimates the cost for the preparation and submission of the Reasonable Accommodation form is $2,925 per response and $2,925 annually for all responses.
Total Cost to Respondent for FCC Form 5626 (Reasonable Accommodation form):
Total annualized capital/startup costs: None.
(b) Total annual costs (O&M): $750
(c) Total annualized cost requested: $750.
Cost to the Respondent:
1 respondent x 2.5 hours x $300 attorney/hour = $750
Total Cost to Respondent: $750
The remaining 1% (1) of respondents will hire a law firm or outside agency to assist the Respondent with completing and filing the Medical Consent form. The typical fee is $300 an hour for representation, plus the cost of supplies (envelopes, postage, cover letter, etc.). For those respondents hiring a law firm, we estimate a burden of approximately 0.50 hours for the attorney to discuss the request with the respondent, and provide legal advice to the Respondent to complete and file the forms, and the Respondent to prepare and file the forms. As noted above, the Commission estimates that 3 hours is spent in the consultation with the attorney (2.5 hours for the Reasonable Accommodation form and 0.5 hours for the Medical Consent form). Thus, the Commission estimates the cost for the preparation and submission of the medical consent form is $150 per response and $150 annually for all responses.
Total Cost to Respondent for FCC Form 5627 (Medical Consent Form):
Total annualized capital/startup costs: None.
(b) Total annual costs (O&M): $150
(c) Total annualized cost requested: $150.
Cost to the Respondent:
1 respondents x 0.50 hours x $300 attorney/hour = $150
Total Cost to Respondent: $150
Total Cost to Respondent for FCC Form 5626 and FCC Form 5627: $750 + $150 = $900
Cost to the Federal Government
Upon receipt of the form, the Commission uses the completed form at varying stages to prepare memoranda, orders, provide copies to the EEOC and district court, to compile data for reports, etc. Accordingly, the Commission staff use the forms throughout the year to perform their duties.
FCC Form 5626 estimated to be filed: 60
60 forms x 25 hours
@ $43.29 per hour (GS-12 Step 5) for processing = $64,935.00
By a Program Analyst
24 forms x 25 hours
@ $71.56 per hour (GS-15 Step 5) for review = $42,936
By an Attorney Advisor
Total = $107,871.00
FCC Form 5627 estimated to be filed: 60
60 forms x 2 hours
@ $43.29 per hour (GS-12 Step 5) for processing = $5,194.80
By a Program Analyst
Total = $5,194.80
Total Cost to the Federal Government: $107,871.00 + $5,194.80 = $113,065.80
This is a new information collection request resulting in a program change/increase to the total respondents of 60, total annual responses of 60 and total annual burden hours of 312 hours. These estimates will be added to OMB’s Active Inventory.
The Commission will publish data regarding the number of requests filed and demographic information in the annual Equal Employment Opportunity EEO Program Status Report (MD-715 Report). However, no personally identifiable information is included in the data that is submitted in connection with any of these reports.
The Commission is not seeking to limit display of the expiration date of the OMB approval nor requesting an exception to the compliance certification in 5 C.F.R. § 1320.9 and related provisions of 5 C.F.R. § 1320.8(b)(3).
There are no exceptions to the Certification Statement.
B. Collections of Information Employing Statistical Methods:
No statistical methods are employed.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ramona Mann |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |