Accommodation Request Form

U.S. MERIT SYSTEMS PROTECTION BOARD
Office of Equal Employment Opportunity
1615 M Street, NW, 6th Floor
Washington, DC 20419

OMB No. 3124-0NEW
Expiration: [date]

ACCOMMODATION REQUEST FORM
Name:
Office:
Supervisor:

Briefly describe your medical condition, and how your condition affects your ability to
perform your job or participate in an interview:
What accommodation are you requesting to perform your job or participate in an
interview?

*NOTE: If your need for an accommodation is not obvious, you must provide documentation from
an appropriate medical professional, such as a doctor, rehabilitation counselor, or vocational
counselor, concerning your disability and functional limitations as they pertain to the
requirements of your current position or the one for which you are applying.
Your medical information will be handled and evaluated by the reasonable accommodation
coordinator, who determine whether there is sufficient documentation to proceed with your
request. If you are unsure of accommodation options, the coordinator will work with you to
determine the most appropriate reasonable accommodation for your condition. You will be
contacted via email. Any documentation you submit will become part of your record of request for
an accommodation, or part of your application package if you are an applicant for employment
with our agency.
Your failure to provide this information may result in the inability of MSPB to grant your request.
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. 117-328, 29 U.S.C. 218d.
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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 applicants for employment and employees
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 to vary from 15 to 30 minutes, with
an average of 30 minutes per response. The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and submitting this form. 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 e-mail to [email protected].

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