Information Collection

Disability Accommodation Request Form

IC 221228 under ICR 201909-3045-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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
1 2019 Disability Accommodation Request Form Disability Accommodation Form.pdf www.nationalservice.gov Form and Instruction
1 Disability Accommodation Request Form 20191227 Disability Request Form_FINAL wPRA and Privacy.docx www.nationalservice.gov Form and Instruction
Disability Accommodation Authorizing Citation.pdf Authorizing Citation IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Accommodation Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection 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
Form and Instruction	1	2019 Disability Accommodation Request Form	Disability Accommodation Form.pdf	www.nationalservice.gov	Yes	Yes	Fillable Fileable
Form and Instruction	1	Disability Accommodation Request Form	20191227 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 %

	Approved	Change Due to Potential Violation of the PRA
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

Title	Document	Date Uploaded
Authorizing Citation	Disability Accommodation Authorizing Citation.pdf	09/10/2019

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