Script for Reasonable Accommodation Request

OMB Number 3124-0NEW, Exp. MM/DD/YYYY
Script for accommodations for MSPB programs under Section 504 of the Rehabilitation Act.
1. What accommodation(s) are you requesting to fully participate in the appeals process?
2. What medical conditions impact your ability to fully participate in the appeals process,
and how do they manifest in your daily life, and what is the prognosis/are the prognoses?
3. What major bodily functions or major life activities are impacted by your disabling
medical condition(s)?
4. What treatment, medication, or other mitigating factors do you typically use to treat or
ameliorate the above condition(s)?
5. When necessary: What supporting documentation (medical records, doctors’ notes, etc.)
support your request?
[The Privacy Act Statement and the Burden Statement will be provided via email and are available
on MSPB’s internal SharePoint website.]
Privacy Act Statement
Authority: The authority for this collection is derived from the Rehabilitation Act of 1973, 29
U.S.C. 701, 791, 794; 29 C.F.R. 1614 (Federal Sector Equal Employment Opportunity); 29 C.F.R.
1630 (Regulations To Implement the Equal Employment Provisions of the Americans With
Disabilities Act); Executive Order 13164, Requiring Federal Agencies to Establish Procedures to
Facilitate the Provision of Reasonable Accommodation (July 26, 2000); Executive Order 13548,
Increasing Federal Employment of Individuals with Disabilities (July 26, 2010); the Pregnant
Workers Fairness Act (effective June 27, 2023), Pub. L. 117-328, 42 U.S.C. 2000gg; and Providing
Urgent Maternal Protections for Nursing Mothers Act (effective December 29, 2022), Pub. L. 117328, 29 U.S.C. 218d. The authority for the system of records notice (SORN) associated with this
collection of information is MSPB-3, Reasonable Accommodations, 90 Fed. Reg. 335 (Jan. 3,
2025).
Purpose: The purpose of this system of records is to allow the U.S. Merit Systems Protection
Board (MSPB) to collect and maintain records on participants in MSPB programs and activities
who request or receive reasonable accommodations or other appropriate modifications from MSPB
for medical reasons; to process, evaluate, and make decisions on individual requests; to track and
report the processing of such requests to comply with applicable requirements in law, regulation,
and policy; and to maintain the confidentiality of the information provided in support of the
accommodation.
Routine Uses: While the information requested is intended to be used primarily for internal
purposes, in certain circumstances it may be necessary to disclose this information externally, for
example to adjudicative bodies, arbitrators, and hearing examiners to the extent necessary to carry
out their authorized duties regarding Federal employment; 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 MSPB’s system of records notice, MSPB – 3, Reasonable
Accommodations, 90 Fed. Reg. 335 (Jan. 3, 2025).

Consequence of Failure to Provide Information: Providing this information is
voluntary. Failure to provide this information may delay or impede the processing of your
reasonable accommodation request.
Burden Statement
Public reporting burden for this data collection is estimated at 30 minutes. The burden estimate
includes the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and documenting data collected from the script. You
are not required to respond to this collection of information unless a valid Office of Management
and Budget (OMB) control number is displayed on this form. Send comments regarding the burden
estimate or any other aspect of the collection of information, including suggestions for reducing
this burden, to Office of the Clerk of the Board, Merit Systems Protection Board, 1615 M Street,
NW, Washington, DC 20419; by fax to 202-653-7130; or by email to [email protected].