Accommodation Request For Persons With Disabilities Disability Program Manager Administrative Instructions U.S. Department of Housing and Urban Development Office of Administration Control Number: RA- - Date: Control Number (RA-Fiscal Year (e.g. 2002)-Sequential # Assigned by Disability Program Manager) Before completing this form, read the reverse. Entries: May be either handwritten or typewritten. Forms Supply: Use local office copier for initial supply and supply and providing completed copies. Copies Retained By: (1) Employee’s Program Office; (2) Disability Program Manager; (3) Employee. Requester Other, such as Immediate Supervisor, Employee Assistance Staff, Disability Program Manager, and Selective Placement Coordinator may help employee complete this section Name Date Signature SSN Organization Position Title Series Grade Requester Comments May be completed if others initiate form. Otherwise, entry not required Receiving Official (e.g., Immediate supervisor, manager, Principal Organization Head, Disability Program Manager, Human Resources Staff, Employee Assistance Program Staff, or Employee/ Labor Relations Staff) Date Received Name *Disapproved Approved In Full Signature Approved In Part Date Comments Concurrence/Approval Employee Assistance Staff, Immediate Supervisor, Principal Organization Head, Disability Program Manager, etc. Name Final Decision Date Received Date Received *Disapproved Approved In Full Signature Approved In Part Date Comments Approved with changes Immediate Supervisor, Principal Organization Head, Disability Program Manager (based on Reasonable Accommodation Committee) Name Funds Availability Date Received Not Available Office of the Chief Financial Officer Name Signature Approved *Disapproved Signature Date Comments Available Date Comments ∗ If disapproved, complete HUD Form 11600. form HUD-1000 (03/2003) American LegalNet, Inc. www.FormsWorkflow.com Privacy Act Statement The Department of Housing and Urban Development (HUD) is authorized to collect this information under Section 501 of the Rehabilitation Act, as amended. The information provided by you will be used primarily to facilitate the processing of your request. Additional uses of the information may be to disclose information to: appropriate Federal, State or Local agencies when relevant to civil, criminal or regulatory investigations or prosecutions, when necessary to adjudicate a claim for benefits or to comply with a law governing the reporting of communicable diseases to Federal agencies in connection with a decision in hiring, retention or the granting of a security clearance; and to Federal agency, court or a party in litigation when HUD is a parity to the proceedings or is served with a subpoena. Furnishing of the information is voluntary; failure to fully complete this form may make it impossible for the Department to process the request. Notice To The Employee With A Disability Completion Instructions If your accommodation request is denied, you have a right to file either an Equal Employment Opportunity (EEO) Discrimination Complaint or a Grievance under the negotiated Union/Management Agreement procedures. Requester Section and Requester Comment Section - to be completed by the employee or on behalf of the employee. Describe the medical condition/limitation and state the reason the accommodation is needed. Identify suggested accommodation or state if an appropriate accommodation is not known. Provide alternative accommodation(s) where possible. Explain what medical documentation is provided (attached) to support the request. If none is considered necessary, so indicate. Include, in the Requester Comment Section, any additional recommendation or comments. This section should also be completed when the form is initiated on behalf of the employee. Receiving Official Section - to be completed by person who receives the request. Indicate date request received; recommended action; justification for recommendation; and signature and date. In the event that the recommended action is disapproved, the comments portion should address one of the following: ♦ Employee does not have a disability. ♦ Employee has a disability, but no accommodation is needed. ♦ The requested accommodation would impose an undue hardship on the Agency. ♦ There is a more appropriate accommodation available. Concurrence/Approval Section - to be completed by the management official who reviews the request. (e.g., Immediate supervisor, manager, Principal Organization Head, Disability Program Manager (based on Reasonable Accommodation Committee) In the event that the recommended action is disapproved, HUD Form 11600, Denial of Reasonable Accommodation Request, must be completed and forwarded to the Disability Program Manager/Reasonable Accommodation Committee for review. The comments/justification should address the following: ♦ Date Request Received ♦ Recommended Action ♦ Recommended Action ♦ Adequacy of Medical Documentation ♦ Signature and Date Final Decision Section - to be completed by the Decision Maker on the request. e.g., Immediate supervisor, , manager, Principal Organization Head. In the event that the final action is approved, identify selected reasonable accommodation in the comments section. In the event that the recommended action is disapproved, HUD Form 11600, Denial of Reasonable Accommodation Request, must be completed and forwarded to the Disability Program Manager/Reasonable Accommodation Committee for final review. Funds Availability Section - to be completed by the Office of the Chief Financial Officer. Form Distribution Copies of this form should be retained, after completion, by the following: ♦ Employee ♦ Originating Office's Administrative Office (if involved in the process) ♦ Disability Program Manager (original and supporting documentation, if any) ♦ Office of the Chief Financial Officer (Funds Availability Approval Office) (Attach additional pages, if necessary) form HUD-1000 (03/2003) American LegalNet, Inc. www.FormsWorkflow.com