Attachment 4
Updated March 28, 2018
SAMPLE LETTER DENYING REQUEST FOR PAS(Insert Date)
From: (Insert Supervisor’s Title and Name)
To: (Insert Requestor’s Title and Name)
Subj: DENIAL OF REQUEST FOR PERSONAL ASSISTANCE SERVICES
1. On (insert request date here), you submitted a request for Personal Assistance Services(PAS). You identified your targeted disability as (insert targeted disability here). You haverequested the following services: (Insert PAS requested).
2. This is to notify you that after assessing all of the information you have provided, as well as
using the resources available to me, your request for PAS is denied. The basis for this decision is
that: (select one or more of the following) You are not a Department of Navy (DON) employee; You do not have a targeted disability;
 Your targeted disability does not create a need for PAS; You are not able to perform the essential functions of your position, even with PAS andany reasonable accommodations; Even with PAS and any reasonable accommodations, your limitations create a direct
threat to safety in the workplace; Providing PAS would impose an undue hardship on the DON.
This decision is based on the following: (Be specific and provide as much detail as necessary tojustify the decision, e.g., why the disability does not qualify as a targeted disability, why the PAS
would result in an undue hardship, etc.)
3. You have the opportunity to:a. Invoke the Alternative Dispute Resolution (ADR) process. To invoke the ADR process,you must submit a written request to (provide RA POC’s contact information) within 14
calendar days of your receipt of this denial letter, or in accordance with your collectivebargaining agreement. ADR may also be appropriately considered as an option in thenegotiated grievance and/or discrimination complaint procedures.
b. File a grievance under the negotiated grievance procedure. If you are a bargaining unit
employee, you have the opportunity to file a grievance, in accordance with (referenceappropriate provisions of the collective bargaining agreement).
c. Initiate the discrimination complaint process pursuant to 29 CFR Part 1614. To do so,
you must contact (provide contact information for EEO Counselor, who is different fromthe RA POC) within 45 calendar days from your receipt of this notification of the initialdenial.
Unless noted as an exception above, you must file a request for ADR, grievance or initiate thediscrimination complaint process within the applicable timeframes for it to be considered atimely filing.
For Official Use Only - Privacy Sensitive:
Any misuse, unauthorized disclosure or unauthorized access may result in civil or criminal penalties, or both.

Subj: DENIAL OF REQUEST FOR PERSONAL ASSISTANCE SERVICES
4. If you are eligible, you also have the option of applying for disability retirement. For furtherinformation regarding this option, please contact the DON Civilian Benefits Center at (insert theDON Civilian Benefits Center contact information). You are further advised that if you areunable to perform the essential functions of your position, appropriate administrative action may
be taken.
5. If you have any questions on the above, or if your need for PAS changes, please contact me or(insert name of servicing RA POC).
(Insert Supervisor’s Name/Signature block)
Copy to:(Insert parties with a need-to-know)

Acknowledgement of receipt:

Employee’s signature

Date

For Official Use Only - Privacy Sensitive:
Any misuse, unauthorized disclosure or unauthorized access may result in civil or criminal penalties, or both.