Reasonable Accommodation Requests

Reasonable Accommodation Requests, FCC Forms 5626 and 5627

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1246 can be found here:

Documents and Forms

Document Name Document Type
Form FCC 5626 Reasonable Accommodation Requests Form
FCC 5626 Reasonable Accommodation Form RA Form with Questionnaire 08172017.docx Form
FCC 5627 Medical Consent Form Medical Consent RM Updates 08172017 (002).docx Form

Information Collection (IC) Details

IC Title:	Reasonable Accommodation Requests	Agency IC Tracking Number:	OWD

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1630 29 CFR 1615

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FCC 5626	Reasonable Accommodation Form	RA Form with Questionnaire 08172017.docx		Yes	Yes	Fillable Fileable Signable
Form	FCC 5627	Medical Consent Form	Medical Consent RM Updates 08172017 (002).docx		Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	312	312
Annual IC Cost Burden (Dollars)	900	900

Documents for IC

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.