Reasonable Accommodation Forms

Requests for Medical and Religious Reasonable Accommodation

Documents and Forms

Document Name Document Type
Form 1 Reasonable Accommodation Forms Form and Instruction
1 COVID 19 Medical Accommodation Request Request for Medical Accommodation writable_06-22-22.pdf www.americorps.gov Form and Instruction
2 Request for Religious Accommodation Request for Religious Accommdation writable.pdf www.americorps.gov Form and Instruction

Information Collection (IC) Details

IC Title:	Reasonable Accommodation Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1605.2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	COVID 19 Medical Accommodation Request	Request for Medical Accommodation writable_06-22-22.pdf	www.americorps.gov	Yes	Yes	Fillable Fileable
Form and Instruction	2	Request for Religious Accommodation	Request for Religious Accommdation writable.pdf	www.americorps.gov	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title: CNCS-10-CEO-PHRI-Personal Health and Religious Information	FR Citation: 86 FR 64458

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	5,955	5,955

Documents for IC

Title	Document	Date Uploaded
No associated records found

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