Personal Assistance Services Request Form
Employee Information
Name:

Email Address:

Work Phone Number:

Secondary Phone Number (Cell /Home):

Major Command:

Organization:

UIC:

Organizational Code:

Position Title, Pay Plan/Series/Grade:
Work Address:
Supervisor Information
Name:

Email Address:

Phone Number:
Request Information - Attach additional documents if needed
1) Identify the targeted disability or diagnosis which limits your ability to perform activities of dailyliving.

2) Describe the full scope of personal assistance services needed to participate in the workplace (orduring work-related travel if this is an official travel PAS request):

3) Indicate the expected duration (frequency and length of time) in which services are required.

4) Complete the following only if you are requesting PAS for official travel:
a. Purpose of work-related travel:b. Dates services are needed:c. TDY Location:

Personal Assistance Services Request Formd. Will you need the personal assistant to accompany you to and from your TDY
destination?
e. If your response to the previous question is “yes”, please provide logistics of the trip
(method of travel, hotel information, etc.)

5) Do you have a specific individual in mind that can provide personal assistant services?

6) If your response to the previous question is “yes,” please provide the individual’s name,telephone number, and e-mail address.

Confirmation of Submission/Receipt
I have read and understand the Privacy Act Statement below, and am confirming the submission(employee) or receipt (supervisor) of this request for Personal Assistance Services:
Privacy Act Statement: The collection of this information is authorized by 29 USC 791 et seq. This information will be used toprocess a request for personal assistance services. As a routine use, the information may be disclosed to: appropriate agency
officials processing or otherwise responding to the request for personal assistance services and/or decisions related to such
request; an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal
proceeding to which the DON is a party or has an interest; to a government agency in order to obtain information relevant to
DON decision(s) concerning personal assistance services; to a congressional office in order to obtain information relevant toDON decision(s) concerning personal assistance services; to an expert, consultant or other person under contract with theDON to fulfill an agency function; to an investigator, administrative judge or complaints examiner appointed for theinvestigation of a formal EEO complaint under 29 CFR 1614; to the Merit Systems Protection Board or Office of Special
Counsel for proceedings or investigations involving personnel practices and other matters within their jurisdiction; to a labororganization as required by the Federal Labor Management Relations Act; to the Office of Personnel Management in makingdeterminations related to disability retirement and benefit entitlement; to officials of the Office of Workers' Compensation
Programs; to the Department of Veterans Affairs; to an employee's private treating physician and to medical personnel
retained by the DON to provide medical services in connection with an employee's health or physical condition related toemployment; and to the Occupational Safety and Health officials when needed to perform their duties. Completion of this form
is voluntary. If this information is not provided, processing the request for reasonable accommodation may not be possible.

Requestor’s Signature:

Date:

Supervisor’s Signature:

Date:

Provide this completed form to your servicing Reasonable Accommodation (RA) Point of Contact(POC) within two (2) business days.

Received by (RA POC’s name):
Date Received by RA POC: