Form FCC Form 5626 FCC Form 5626 Reasonable Accommodation Form with Questionnaire

OMB Control No. 3060-1246

Est. Avg. Burden per Response: 5 Hours

Federal Communications Commission The Office of Workplace Diversity

REQUEST FOR REASONABLE ACCOMMODATION

This record must be maintained separate and apart from personnel file

1.

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APPLICANT’S OR EMPLOYEE’S NAME

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APPLICANT’S OR EMPLOYEE’S PHONE #

__________________________________________

APPLICANT’S OR EMPLOYEE’S EMAIL

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__________________________________________

DATE OF REQUEST

__________________________________________

SUPERVISOR AND PHONE #

__________________________________________

EMPLOYEE’S OFFICE

2. TYPE OF ACCOMMODATION REQUESTED, IF KNOWN (Be as specific as possible, e.g., assistive technology, reader, interpreter, schedule change)

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3. REASON FOR REQUEST

If accommodation is time sensitive, please explain:

4. SPECIFIC INFORMATION REGARDING CONDITION

a. Do you have an impairment? Yes ☐ or No ☐

b. If yes, what is the impairment: ___________________________________________

c. Evidence of the impairment: ________________________________­­_____________

d. Is the impairment affecting major life activity? Yes ☐ or No ☐

e. If yes, what is the major life activity: Check all that apply

Walking	☐	Standing	☐	Lifting	☐
Speaking	☐	Reaching	☐	Sleeping	☐
Breathing	☐	Interacting with Others	☐	Working	☐
Hearing	☐	Learning	☐	Reproduction	☐
Seeing	☐	Performing manual tasks	☐	Eating	☐
Thinking	☐	Caring for Oneself	☐	Controlling Bowels	☐
Sitting	☐	Concentrating	☐	Running	☐
Others (describe)	☐

f. What, if any, job functions are you having difficulty performing and/or employment benefits are you having difficulty accessing?

g. What limitation is interfering with your ability to perform your job or access an employment benefit?

h. Have you had any accommodations in the past for this same limitation? If yes, what were they and how effective were they?

i. If you are requesting a specific accommodation, how will that accommodation assist you?

j. Is the condition permanent or temporary? If temporary, how long is the condition projected to last?

______________________ __________________________ ________________________

APPLICANT SIGNATURE RECEIVING OFFICIAL NAME RECEIVING OFFICIAL SIGNATURE

5. FCC-ACC No.:___________________________ (Reasonable Accommodations Coordinator will assign number)

Privacy Act Statement

Authority: The Rehabilitation Act of 1973, as amended, 29 U.S.C. § 791; Executive Order 13164, Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommodation, 65 Fed. Reg. 46,563 (Jul 28, 2000); and Equal Employment Opportunity Commission’s Policy Guidance on Executive Order 13164: Establishing Procedures to Facilitate the Provision of Reasonable Accommodation, Directives Transmittal Number 915.003, October 20, 2000.

Purpose: The principal purpose for collecting this information is to permit the Federal Communications Commission (FCC) to assess whether individuals are entitled to a reasonable accommodation. Additionally, this information is being collected and maintained by the FCC to record and track requests for reasonable accommodation by individuals with disabilities, their provision, and the disposition of such requests. Information collected in connection with a request for reasonable accommodation is confidential and may be shared with Agency officials or Agency contractors only when those other individuals need to know the information to make determinations on a reasonable accommodation request or to assist the Reasonable Accommodations Coordinator in making such a determination.

Routine Uses: The records and information in the records may be used pursuant to the Routine Uses for the system found in the System of Records Notice EEOC/GOVT-1, Equal Employment Opportunity (EEO) in the Federal Government Complaint and Appeal Records, 81 Fed. Reg. 81,116 (Nov. 17, 2016).

Effect of Disclosure: The provision of information is voluntary; however, if you do not provide this information, the FCC may not provide you with an accommodation, and you may not receive important information.

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT

We have estimated that each response to this collection of information will take 5 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Paperwork Reduction Project (3060-1246), Washington, DC 20554. We will also accept your comments via the Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED REQUESTS TO THIS ADDRESS. Remember - you are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-1246.

THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. 3507

FCC Form 5626

2017

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