DFC 195 

The Privacy Act of 1974, 5 U.S.C. § 552a rules apply. 

CONFIRMATION OF REQUEST FOR REASONABLE ACCOMMODATION 

AND 

PERSONAL ASSISTANCE SERVICES

Request Number: ____________ (To be completed by Reasonable Accommodation Coordinator) 

APPLICANT/EMPLOYEE NAME: 

NAME OF INDIVIDUAL COMPLTEING FORM: 

TODAY’S DATE: 

DATE OF REQUEST: 

SUPPORTING DOCUMENTATION ATTACHED: 

 YES 

 NO 

APPLICANT/EMPLOYEE TELEPHONE NUMBER: 

APPLICANT OR EMPLOYEE STREET ADDRESS: 

APARTMENT OR OFFICE NUMBER: 

CITY, STATE, ZIP CODE: 

EMAIL ADDRESS: 

ACCOMMODATION OR PERSONAL ASSISTANCE SERVICE REQUESTED. While you do not have to have 

a particular accommodation in mind, please be as specific as possible, e.g., adaptive equipment, 

reader, interpreter, etc. Please note, Personal Assistance Services are not available to applicants, 

pursuant to 29 C.F.R. § 203 (5)(i). 

REASON FOR REQUEST. If request is time sensitive, please explain. 

DOCUMENTATION. Please attach supporting documentation regarding your disability and need for 

accommodation. DFC may also seek additional information if necessary. DFC does not require any 

supporting documentation or information when the disability and need for accommodation are obvious

or when the employee or applicant has already provided DFC with sufficient information to document 

the existence of the disability and his/her functional limitations. 

SUBMIT COMPLETED FORM TO REASONABLE ACCOMMODATION COORDINATOR. 
Authority: The Rehabilitation Act of 1973, as amended, 29 U.S.C. § 791 et seq.; Federal Sector 

Equal Employment Opportunity, 29 C.F.R. Part 1614; Executive Order 13548, Increasing Federal 

Employment of Individuals with Disabilities, 75 Fed. Reg. 45039 (Jul. 30, 2010); Executive Order 

13164, Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of 

Reasonable Accommodation, 65 Fed. Reg. 46,563 (Jul 28, 2000); and Equal Employment 

Opportunity Commission’s Policy Guidance on Executive Order 13164: Establishing Procedures 

to Facilitate the Provision of Reasonable Accommodation, Directives Transmittal Number 

915.003, October 20, 2000.

Purpose: The principal purpose for collecting this information is to permit the U.S. International 

Development Finance Corporation (DFC) to assess whether individuals are entitled to a 

reasonable accommodation. Additionally, this information is being collected and maintained by 

the DFC to record and track requests for reasonable accommodation by individuals with 

disabilities, their provision, and the disposition of such requests. Information collected in 

connection with a request for reasonable accommodation is confidential and may be shared 

with Agency officials or Agency contractors only when those other individuals need to know the 

information to make determinations on a reasonable accommodation request or to assist the 

Reasonable Accommodations Coordinator in making such a determination.

Routine Uses: While the information requested on this form is intended to be used primarily 

for internal purposes, in certain circumstances it may be necessary to disclose this information 

externally, for example to disclose the information to another agency to comply with laws 

governing health and safety or to disclose to adjudicative bodies such as the Equal Employment 

Opportunity Commission. A full list of Routine Uses for the collection can be found in the 

System of Records Notice DFC/09, Reasonable Accommodation Records, 86 FR 63000 (Nov. 15, 

2021) and OPM/GOVT-10, Employee Medical File System Records, 75 FR 35099 (June 21, 2010), 

amended 80 FR 74815, (Nov. 30, 2015).

Effect of Disclosure: The provision of information is voluntary; however, if you do not provide 

this information, the DFC may not provide you with an accommodation, and you may not 

receive important information.