FEMA Reasonable Accommodation Medical Request Form

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
278716	FEMA Reasonable Accommodation Medical Request Form (FEMA Form FF-256-FY-25-100) Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202601-1660-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DHS/FEMA	Agency Tracking No: 1660-NW179
Title: FEMA Reasonable Accommodation Medical Request Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/13/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	232	0
Time Burden (Hours)	116	0
Cost Burden (Dollars)	0	0

---

Abstract: FEMA’s new form supports a fair, efficient, and consistent process for evaluating employee requests for reasonable accommodations. It ensures that medical information is collected by license health care providers, helping the agency make informed decisions. FEMA is streamlining the process by ensuring that all necessary and relevant information is consistently captured. By providing a clear and uniform structure, it enhances efficiency for employees and licensed health care providers, while reducing the potential for delays caused by incomplete or insufficient submissions of medical documentation.

---

Authorizing Statute(s): US Code: 29 USC 701 Name of Law: Rehabilitation Act of 1973
   EO: EO 13163 Name/Subject of EO: Increasing the Opportunity for Individuals With Disabilities To Be Employed in the Federal Governmen
   US Code: 5 USC 552a Name of Law: Privacy Act of 1974
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 39411	08/15/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 6236	02/11/2026
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
FEMA Reasonable Accommodation Medical Request Form (FEMA Form FF-256-FY-25-100)	FEMA Form FF-256-FY-25-100	FEMA Reasonable Accommodation Medical Request Form

---

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	232	0	0	232	0	0
Annual Time Burden (Hours)	116	0	0	116	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

---

Annual Cost to Federal Government: $469,728

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/13/2026

---

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].