Form 1 COVID 19 Medical Accommodation Request

OMB Control No. 3045-0196
Expiration: XX/XX/XXXX
This form is available in written and accessible formats.

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 and submit it to the Disability Program Manager at
[email protected].
2. The Disability Program Manager will review your request and notify you if Part 2 must also be completed.
3. If you are notified, your medical provider must complete Part 2 of this form and you must submit it to the
Disability Program Manager at [email protected].
4. If more space is needed, please attach documents as necessary.
AmeriCorps is required to protect the confidentiality of any medical information you provide.
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,
CNCS-10-CEO-PHRI, Personal Health and Religious Information (86 FR 6458).
Paperwork Reduction Act Statement
This information is collected to determine whether you are entitled to an accommodation under law. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB Control Number. The
public reporting burden for both Part 1 and Part 2 of this form is estimated to average 3 hours per response, including the time for
reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding burden
estimates or any other aspect of this form to the AmeriCorps Information Collection Clearance Officer at [email protected].

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

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OMB Control No. 3045-0196
Expiration: XX/XX/XXXX

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?

(Note: if either: (a) your disability and the need for reasonable accommodation are obvious; or (b) you have already
provided the agency with sufficient information to document the existence of the disability and functional
limitations, you may indicate (a) or (b) in lieu of responding to this question)

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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OMB Control No. 3045-0196
Expiration: XX/XX/XXXX

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.
Please provide medical information to 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). 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].
1. What activity(ies) does the impairment limit?

2. To what extent does the impairment limit the individual's ability to perform the activity(ies)?

3. Why does the individual require reasonable accommodation or the particular accommodation requested?

4. How will the accommodation assist the individual to apply for a job, perform the essential functions of a job, or
enjoy a benefit of the workplace?

5.a. Is this a temporary medical condition/circumstance?

b. If temporary, 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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