U.S. Department of Housing and Urban Development Office of Administration REASONABLE ACCOMMODATION INFORMATION REPORTING FORM Enter the following information about the employee or applicant who requested the reasonable accommodation: Requester's Name: Office & Location: Control Number Assigned: RA- 1. Reasonable Accommodation: (Check one) Approved Denied (if denied, attach copy of the Denial of Reasonable Accommodation Request Form HUD-11600).) (Enter Date of Receipt) 2. Date Reasonable Accommodation requested: Name and Title of person who received initial request: 3. Date Reasonable Accommodation request referred to Decision Maker (i.e., Supervisor, Disability Program Manager, Principal Organization Head): (Enter Date of Receipt) Name and Title of Decision Maker: 4. Date Reasonable Accommodation approved or denied: (Enter Date of Decision) 5. Date Reasonable Accommodation provided: (Enter, if different from date approved) 6. If time frames outlined in the Reasonable Accommodation Procedures were not met, please explain Why: 7. Current position or, if an applicant, desired position of the individual requesting Reasonable Accommodation (including position title, series, grade level, and office): American LegalNet, Inc. www.FormsWorkflow.com form HUD-11601 (03/2003) U.S. Department of Housing and Urban Development Office of Administration REASONABLE ACCOMMODATION INFORMATION REPORTING FORM, Page 2 8. Reasonable Accommodation needed for: (Check one) Application Process Performing Job Functions or Accessing the Work Environment Accessing a Benefit or Privilege of Employment (e.g., attending a training program or social event): 9. Type(s) of Reasonable Accommodation provided (e.g., adaptive equipment, staff assistant, removal of Architectural barrier): 10. Type(s) of reasonable accommodation provided (if different from what was requested): 11. Was medical information required to process this request? If yes, explain why. 12. Sources of technical assistance, if any, consulted in trying to identify possible Reasonable Accommodations (e.g., Job Accommodation Network, disability organization, Disability Program Manager): 13. Comments: Name and Title of person completing this form Date Room Number Telephone Number/Extension Attach copies of all documents obtained or developed in processing this request. American LegalNet, Inc. www.FormsWorkflow.com form HUD-11601 (03/2003)