Information Collection

Reasonable Accommodation Forms

IC 250655 under ICR 202205-3045-002 · OMB 3045-0196.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.