References: The Rehabilitation Act of 1973, as amended, Title 29, C.F.R. Part 1630, Executive Order 13164

Written Request for Reasonable Accommodation

The Defense Intelligence Agency will provide a reasonable accommodation (RA) to the known physical or mental impairment of a qualified 

individual with a disability, provided the accommodation is necessary for the performance of essential job duties, is effective for the individual 

and the agency, is related to the job, and does not pose an undue hardship or create a direct threat to the Agency.

 An individual with a disability is a person with a physical or mental impairment that substantially limits one or more major life activities,

 has a record of such an impairment; or is regarded as having such an impairment.

A completed request for reasonable accommodation includes:

Request for Reasonable Accommodation.

 Substantiating medical documentation form of health care professional (to be submitted directly to the RA team).

Such documentation is used to substantiate that an individual’s medical condition rises to the level of disability and the functional limitations of 

the impairment. “Health care professional” includes but is not limited to doctors, nurses, psychologists, therapists, and vocational rehabilitation 

specialists. When the disability and/or need for accommodation are obvious, documentation is not required.

Requester’s Name: Employee ID (if applicable): Series and Grade:

PART I—REQUESTER’S CONTACT INFORMATION

Accommodation(s) Requested (please specify):

Assistive Technology

Alternative Work Schedule

Ergonomic Equipment

Service (e.g. SLI, reader, note taker)

Telework

Workspace Modification 

Other

Not Sure

Authority: Federal Rehabilitation Act of 1973, as amended, Rehabilitation Act–29 CFR 1614.203, as amended, Americans with Disabilities Act, as amended, Executive Order 13164,

“Establishing Procedures to Facilitate the Provision of Reasonable Accommodation,” as amended, DoD Directive 1020.02, “Diversity Management and Equal Opportunity in the

Department of Defense,” as amended, DIA Directive (DIAD) 1020.100, “DIA Equal Employment Opportunity and Diversity Program,” 15 May 2014.

Purpose: To evaluate information in response to a Reasonable Accommodation Request.

Routine Uses: Routine uses of the information are consistent with the Defense Reasonable Accommodations and Assistive Technology Records, System of Records Notice DoD 0007. 

Additional information is available at https://www.federalregister.gov/documents/2021/07/22/2021-15601/privacy-act-of-1974-system-of-records

Disclosure of Information: Providing this information is voluntary; however, failure to complete the form in its entirety could result in a denial or delay of the requested service.

Instructions:

1. Requesting individual complete the Written Request for Reasonable Accommodation form.

2. Submit request form to supervisor, or in the case of applicant, directly to the RA team or Office of Human Resources representative.

3. Supervisor forwards request to RA team.

4. Requesting individual directly submits medical documentation to RA team.

Position/Title:

Telephone:

Supervisor’s Name:

Directorate/Office:

VOIP/DVTC:

Supervisor’s Telephone:

Work Location:

Email:

Supervisor’s Email:

PART II—ACCOMMODATION REQUEST

Do you currently use any accommodation? Yes No

If yes, list accommodations

Indicate the major life activities substantially limited by the impairment.

How does your limitation impact the performance of your essential job duties?

Employee Signature:

PLEASE RETURN FORM TO:

Mailing: DIA 7400 Pentagon

Attn: EO/Reasonable Accommodation

Washington, DC 20301

TO BE COMPLETED BY THE REASONABLE ACCOMMODATION TEAM

Request Date: Supervisor Signature: Request Date:

Email:

NIPR—reasonableaccommodations@dodiis.mil

Phone: (202) 231-8178

Fax: (202) 231-6486

Received Date:

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Appendix B Date:

Received By:

IAP Date:

Case Number:

Other:

Medicals Sufficient IAP Required

Close Date:

Yes No Yes No

DIA 1020.2