Attachment 2 

AMS Directive 4720.1 

4/26/04 

REASONABLE ACCOMODATION FORM 

CONFIRMATION OF REQUEST FOR REASONABLE ACCOMMODATION 

Applicant or Employee Name: 

________________________________________________________________________ 

Telephone Number: _______________________ 

Employee Only: 

Occupational Series _______ 

Grade _______ 

Applicant or Employee E-mail address: _______________________________________ 

Date of Request: _________________________ 

Employee’s Agency: ______________________________________________________ 

1. Accommodation Requested (be as specific as possible)

2. Reason for Request

3. If accommodation is time sensitive, please explain:

This request form shall be given to your immediate supervisor or Mission 

Area/Agency Disability Employment Program Manager. This form is necessary for 

recordkeeping purposes only and will not delay the processing of your initial 

request.

Today’s Date: __________________________ 

 

1
REASONABLE ACCOMMODATION INFORMATION REPORTING FORM

Name of Individual Requesting Accommodation: 

________________________________________________________________________ 

Agency and Office of the Requesting Individual: 

________________________________________________________________________ 

1. Reasonable Accommodation (check one) 

______ Approved - Name and Title of Deciding Official: _________________________ 

______ Denied (attach form AD-1165 "DENIAL OF REASONABLE 

ACCOMMODATION REQUEST") 

2. Date accommodation requested and date referred, if applicable: 

________________________________________________________ 

3. Name and position of individual to whom request was made: 

________________________________________________________ 

4. Date accommodation approved or denied: 

________________________________________________________ 

5. Date accommodation provided: 

________________________________________________________ 

6. If time frames outlined in the Reasonable Accommodation Procedures were not met, 

please explain why: 

7. Job held or desired by individual requesting accommodation (include occupational 

series, grade level and office): 

 

2
8. Accommodation required for: 

_____application process 

_____performing job functions or accessing work environment 

_____accessing a benefit or privilege of employment (e.g., attending training, social 

event) 

9. Type(s) of accommodation requested: 

10. Type(s) of accommodation provided: 

11. Was medical information required to process this request? If yes, explain why: 

12. Cost, if any, of accommodation: 

13. Sources of technical assistance, if any, consulted (Job Accommodation Network, 

 family member, rehabilitation counselor, other) 

 

3
DENIAL OF REASONABLE ACCOMMODATION REQUEST 

Name of Individual Requesting Accommodation: _______________________________ 

1. Type(s) of reasonable accommodation requested: 

2. Request for accommodation denied because (may check more than one) 

___Accommodation ineffective 

___Accommodation would cause undue hardship 

___Medical documentation inadequate 

___Accommodation would require removal of an Essential Function 

___Accommodation would require lowering of performance/production standard 

___Other (please specify) 

3. Detailed reason(s) for the denial of the accommodation (Must be specific, e.g., why 

accommodation is ineffective or causes undue hardship). 

4. If the requestor proposed one type of reasonable accommodation and the request is

denied, and rejected an offer of an alternative accommodation, explain the reason for 

denial of the original requested accommodation and how the offered alternative 

accommodation would be effective. 

Name and Title of Deciding Official __________________________________________ 

Signature of Deciding Official_______________________________________________ 

Date reasonable accommodation denied__________________________ 

 

4
If an individual wishes to request reconsideration of this decision, s/he may take the 

following steps: 

• Ask the decision maker to reconsider the denial and provide additional supporting 

information; or 

• If the decision maker does not reverse the denial, and the decision maker is the 

individual’s supervisor, the individual may ask the office chief/director to review 

the request; or 

• If the decision maker is the office chief or director, the individual can ask the 

Agency Disability Employment Program Manager to review the request; or 

• If the decision maker is the Agency Disability Employment Program Manager, 

the individual can ask the Departmental Disability Employment Program

Manager to review the request. 

If an individual wishes to file an EEO complaint, or pursue Merit Systems Protection 

Board (MSPB) and union grievance procedures if applicable, s/he must take the 

following steps: 

• For an EEO complaint pursuant to 29 C.F.R. § 1614, contact an AMS EEO 

counselor within 45 days from the date of this notice of denial of reasonable 

accommodation; or 

• For a collective bargaining claim, file a written grievance in accordance with the 

provisions of the Collective Bargaining Agreement, or Administrative grievance 

procedure as appropriate; or 

• Initiate an appeal to the Merit Systems Protection Board within 30 days of an 

appealable adverse action as defined in 5 C.F.R. § 1201.3; or 

• Utilize the Alternative Dispute Resolution (ADR) process as outlined in the 

Administrator’s Memorandum dated September 18, 2002. Pursuing the ADR 

process does not relieve the individual of his/her responsibility to adhere to the 

other applicable time-frames. 

 

5
 

USDA CAP Partnership Accommodation Request 

To request assistive technology accommodations and services through the USDA 

CAP Partnership Program, please complete this form and Appendix A of the 

Reasonable Accommodations Procedures (DM 4300-002). For help in completing 

these forms or for help in identifying an effective accommodation, contact the USDA 

TARGET Center staff at 202-720-2600 (v/tty), or the Mid-West TARGET Center 

staff at 314-539-3800 (v/tty). Please submit the completed forms via fax or email to 

either TARGET office using the contact information at the end of this form. 

Employee:___________________________________Phone/TTY:___________ 

Email: ________________________________________ 

Supervisor:___________________________________Phone/TTY:__________ 

E mail: ________________________________________ 

 ITSupport:___________________________________Phone/TTY:___________ 

E mail: ________________________________________ 

 

Disability Employment 

Program Manager: ______________________________Phone/TTY: ________ 

E mail: _________________________________________

Delivery Address of person receiving the equipment order: 

_______________________________________________________________________ 

_______________________________________________________________________ 

_______________________________________________________________________ 

_______________________________________________________________________ 

 

6
Please identify the item you are requesting including make, model and vendor (if 

applicable). For computer installed equipment and software, please answer 

questions one through eight on pages 7 and 8. 

_______________________________________________________________________ 

_______________________________________________________________________ 

Please identify your disability for CAP’s record keeping purposes. Additional medical 

documentation and information may be requested by CAP and/or your agency to 

determine disability. Do not forward medical documentation to TARGET Center. 

Contact your disability employment program manager or mission area designee if you or 

your supervisor needs assistance with identifying disability. 

Hearing Vision 

Cognitive Mobility/Dexterity Other (identify) _______________________ 

Please explain how your disability limits your ability to perform essential job functions 

and how the requested accommodation will assist you. 

_______________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

For computer installed software and equipment only. To ensure compatibility 

between the requested computer equipment or software and your current system, please 

answer the following questions with assistance from your IT support person. 

1.What operating system does your computer use? Windows 95 Windows 98 

 Windows 2000 Windows NT Windows XP Macintosh 

 Other (Identify)_____________________________________ 

2. What is the brand name of your computer? _______________________ 

3. What is your processor speed? ____________________ 

 (Minimum: 266 MHz. * 500 MHz or faster is recommended for best results). 

4. How many MB RAM does your computer have?______________ 

 (Minimum: 128 MB RAM. *256 MB RAM is recommended) 

5. How much free space do you have on your hard drive?_______________ 

 (195 MB free disk space. 150 MB to install Dragon) 

 

7
6. Does your computer have a cd-rom drive? _________________________

7. Does your computer have a sound card? If so, what type?

 ___________________________________________________________ 

 

8. Does your computer have a modem? If so what speed? 

 ____________________________________________________________ 

I certify the above information is correct to the best of my knowledge as indicated by my 

signature below. Signature certifies that the accommodation is necessary for a person 

with a disabling condition to accomplish an essential job requirement and that USDA 

Reasonable Accommodations Procedures have been followed. Any equipment purchased 

through the USDA CAP partnership becomes property of the USDA, not the individual 

with a disability. Further, the equipment maintenance beyond initial warranty period and 

additional supplies after receipt of equipment is the responsibility of the employee’s 

agency. 

_____________________________ ________________ Signature of Employee Date 

_____________________________________ ____________________ Signature of Supervisor Date 

Contact Information: 

USDA TARGET Center Mid-West TARGET Center (St. Louis) 

202-720-2600 (v/tty) 314-335-8800 (v/tty) 

202-720-2681 (Fax) 314-539-3808 (Fax) 

Email: target-center@usda.gov Midwest-Target @stl.rural.usda.gov

 Serving the Midwest and Western US. 

Website: http://www.usda.gov/oo/target 

 

8