DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

AUTHORIZATION TO RELEASE MEDICAL RECORDS/INFORMATION

PRIVACY ACT STATEMENT (5 U.SC. §552a) 

AUTHORITY: Public Law 92-261

PRINCIPAL PURPOSE: Used for processing request for reasonable accommodation by Federal Law Enforcement Training Centers 

employees, applicants for employment (as needed), students and some contract employees.

ROUTINE USES: Information will be used (a) to determine effective reasonable accommodation; (b) to respond to general requests 

for information under the Freedom of Information Act; (c) to respond to request for legitimate outside individuals 

or agencies (e.g., Review by Federal Health Organization or other medical authority, White House, Congress, 

Equal Employment Opportunity Commission) regarding the status of a request for reasonable accommodation.

DISCLOSURE: Voluntary, however, failure to complete all appropriate portions of this form may lead to delay in processing.

I, (Name), hereby authorize the Federal Law Enforcement Training Centers 

(FLETC) Disability Program Manager to release my medical records/information1to the FLETC 

Reasonable Accommodation Team comprised of a representative from the Equal Employment Opportunity 

(EEO) Office, Human Capital Office, and Office of Chief Counsel, for use within the scope of my request 

for reasonable accommodation and the individualized assessment. The documents and 

information resulting from this waiver will only be shared with my supervisor and those FLETC 

employees, including the FLETC Medical Liaison Officer, and medical contractors and professionals 

who have a “need to know” this information within the scope of this individualized assessment. 

The FLETC will rely on the following information during the individualized assessment of the request 

for reasonable accommodation: 

• Nature, severity and duration of the impairment(s),

• Activity or activities that the impairment(s) limits,

• Extent to which the impairment(s) limits the ability to perform the duties of the employees job,

• Recommendations for reasonable accommodation, and

• Why the recommended reasonable accommodation is needed.

The foregoing authorization shall continue in full force and effect unless revoked by me in writing; or a 

final decision of the request for Reasonable Accommodation is reached. 

(Requester’s Signature) (Date)

Please submit the completed form to:

Disability Program Manager

Federal Law Enforcement Training Centers, EEO Office

1131 Chapel Crossing Road, Town House 379 

Glynco, Georgia 31524 

Phone (912) 267-3316 

Fax (912) 261-4586 

Email: FLETC-EEO@fletc.dhs.gov 

1 The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from 

requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To 

comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. 

"Genetic information," as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's 

genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus 

carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive 

reproductive services.

FLETC Form 256-05-04 (01/20) Page 1 of 1