Form FCC Form 5627 FCC Form 5627 Medical Consent Form

OMB Control No. 3060-1246

Est. Avg. Burden per Response: 0.16 Hours

Federal Communications Commission

Office of Workplace Diversity

445 12^th Street SW

Office 5C-720

Washington, DC 20554

MEDICAL CONSENT FORM

Please check the appropriate block and sign below. Return the original signed copy to this office and keep a copy for your records.

I hereby authorize the Federal Communications Commission (FCC) Reasonable Accommodations Coordinator to request and receive materials and information about me pertinent to my request for accommodation based on an asserted disability. I authorize FCC officials to contact the medical professionals I have listed in my requests and supporting materials to collect further information about my medical condition as it may pertain to my request. I understand that it may be necessary to reveal to others my identity and medical information regarding my request to FCC officials.

I also understand that any information collected to process my request will be considered by FCC when making the decision to approve or disapprove my request and will become a part of my record of request for an accommodation. This documentation will not become a part of my personnel file.

Please check one of the following blocks and sign below:

_______ Consent. I have read and understand the above notice and authorize FCC officials to request and receive medical material and information about me pertinent to my request for accommodation.

_______ Consent Denied. I have read and understand the above notice. I do not want FCC officials to request and receive medical material and information about me. I understand that the FCC’s lack of access to this information is likely to impede the review of my request and could result in the FCC being unable to grant my request.

Signature Date

Name Phone

Address

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 0.16 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 5627

2017

Page 1