2 Reasonable Accommodation: Medical

REQUEST FOR A MEDICAL
REASONABLE ACCOMMODATION
By signing this form, you declare that the information you provide is true and correct to the best of your
knowledge and ability. Any intentional misrepresentation to the Federal Government may result in legal
consequences, including termination or removal from Federal Service.
To request a medical reasonable accommodation:
1. You must complete Part 1 of this form.
2. Your medical provider must complete Part 2 of this form.
3. If more space is needed, please attach documents as necessary.
4. When both parts are completed, you must submit the form to the Disability Program Manager at
[email protected].

Privacy Act Statement
Authority:
We are authorized to collect the information on this form by Sections 501 and 505 of the Rehabilitation Act of
1973 (Pub. L. 93-112) (Rehab. Act), as amended, as these sections appear in volume 29 of the United States
Code, beginning at section 791. Section 501 prohibits employment discrimination against individuals with
disabilities in the Federal sector. Section 505 contains provisions governing remedies and attorney’s fees under
Section 501. Section 508 of the Rehabilitation Act requires that Federal agencies ensure comparable access for
persons with disabilities whenever an agency uses electronic or information technology, unless such access
would impose an undue burden on the agency.
Purpose:
This information is being collected and maintained to document your need for a reasonable accommodation
and is required to establish that you have a covered disability, the functional limitations of your disability,
and the need for reasonable accommodation. If you fail to fully complete the form or refuse to provide the
requested documentation, your reasonable accommodation process could break down and your request may
be denied.
Routine Uses:
The information requested on this form is intended to be used primarily for internal purposes. However, in
certain circumstances it may be necessary to disclose this information externally. Examples include: to disclose
information to: a Federal, state, or local agency to the extent necessary to comply with laws governing
reporting of communicable disease or other laws concerning health and safety in the work environment; to
adjudicative bodies (e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the extent
necessary to carry out their authorized duties regarding Federal employment; to contractors, grantees, or
volunteers as necessary to perform their duties for the Federal Government; to other agencies, courts, and
persons as necessary and relevant in the course of litigation, and as necessary and in accordance with
requirements for law enforcement; or to a person authorized to act on your behalf. A complete list of the
routine uses can be found in the system of records notice associated with this collection of information, CNCS10-CEO-PHRI, Personal Health and Religious Information (86 FR 6458).

250 E Street SW
Washington, D.C. 20525
202-606-5000 / 800-942-2677

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Reasonable Accommodation Tracking Number_____________ (will be added after form is submitted)
Person Requesting Accommodation

Date of Request

Office / Program

Work / Volunteer Location

Position

Supervisor

Phone Number and Email Address

INFORMATION ABOUT YOUR REASONABLE ACCOMMODATION REQUEST
1.

What type of accommodation are you requesting? Be as specific as possible – for example, adaptive
equipment, readers, sign language interpretation, personal assistance in the workplace, modification of your job,
etc.

For questions 2 and 3, you are not required to reveal your exact medical condition/diagnosis, but you must
provide enough information to help us arrive at a decision:
2. Why is the requested accommodation medically necessary?

3. How will the requested accommodation (or an alternate accommodation) be effective and allow you to
perform the essential functions of your position?

4. If the accommodation you’re requesting is time sensitive, please explain:

Requester’s Signature
I declare to the best of my knowledge and ability that the foregoing is true and correct.

Print Name

Date

250 E Street SW
Washington, D.C. 20525
202-606-5000 / 800-942-2677

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Part 2 – To be Completed by the Person Requesting Exemption’s Medical Provider
Patient Name

Medical Certification of Need for a Reasonable Accommodation
Dear Medical Provider:
The individual named above is seeking a reasonable accommodation for a medical condition. Please complete this
form to assist AmeriCorps in its reasonable accommodation process. An accommodation is a logical adjustment
made to a job and/or the work environment which enables a qualified employee with a disability to successfully
perform the essential duties or functions of the position.
The medical information you provide should demonstrate that the individual has one or more physical or mental
impairments that substantially limit(s) one or more major life activity (e.g., walking, speaking, breathing, hearing,
seeing, thinking, sitting, standing, reaching, interacting with others, learning, performing manual tasks, caring for
themself, concentrating, lifting, working, sleeping), and that there is a relationship between the substantially limiting
medical condition(s) and the requested accommodation.
You do not have to provide the exact diagnosis, but the information provided should indicate that the requested
accommodation is based on a medical condition and will allow the requestor to perform the essential functions of
their position. Attach additional pages if necessary.
If you have questions about completing this form, please contact the Disability Program Manager at
[email protected].

The condition described above is:

Temporary

Long term/permanent

If this is a temporary condition or medical circumstance, when is it expected to end?

Medical Provider Name/Title/Address/Telephone Number

Medical Provider Signature

Date

250 E Street SW
Washington, D.C. 20525
202-606-5000 / 800-942-2677

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