DEPARTMENT OF HOMELAND SECURITY 

U.S. Coast Guard 

REQUEST FOR REASONABLE ACCOMMODATION OR PERSONAL ASSISTANCE SERVICE 

When requesting a reasonable accommodation, an applicant or employee must notify the Coast Guard of an adjustment or change concerning some aspect 

of the application process, the job, or a benefit of employment for a reason related to a medical condition. An applicant or employee may request a 

reasonable accommodation at any time. The reasonable accommodation process begins as soon as an oral or written request for accommodation is made to 

any supervisor or manager in an employee’s chain of command. A family member, health professional, or other representative may also request an 

accommodation on behalf of an employee or applicant. Completion of this form is optional, but encouraged for recordkeeping purposes. 

1. EMPLOYEE/APPLICANT NAME 2. OFFICE LOCATION AND ADDRESS 

3. TITLE, OCCUPATIONAL SERIES AND GRADE 4. TELEPHONE NUMBER 

5. DECISION MAKER'S NAME 6. DECISION MAKER'S TELEPHONE NUMBER 

7. Briefly describe the medical condition requiring accommodation or personal assistance service. (Agency may request medical documentation to support

 request(s) made.)

 8. Briefly describe the specific accommodation or personal assistance service being requested. (Be as specific as possible, e.g., assistive technology, reader,

 interpreter, schedule change, etc.)

 9. Explain how the requested accommodation or personal assistance service would assist you in: (1) performing the essential duties of your position, (2) using 

the job application process, (3) taking advantage of a benefit or privilege of employment, or (4) performing an activity of daily living (e.g. training, services, 

facilities, sponsored functions, etc.). 

10. If your requested accommodation is time sensitive, please explain. 

11. EMPLOYEE/APPLICANT/REPRESENTATIVE SIGNATURE 12. DATE 

CG-6079 (06/20) PROVIDE FORM TO SUPERVISOR – COPY FOR EMPLOYEE/APPLICANT 
 

Privacy Act Notice 

Authority: The Rehabilitation Act of 1973, as amended, 29 U.S.C. 791; Executive Order 13164, dated July 26 2000, 

Section 1(b)(9); 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 United States Coast Guard will use this information solely to record and track requests for reasonable 

accommodation or personal assistance service by individuals with disabilities, their provision, and the disposition of such 

requests. 

Routine Uses: The information will be used by and disclosed to Coast Guard personnel or other agents who need the 

information to assist in activities related to the provision of reasonable accommodations. Additionally, the Coast Guard 

may share the information pursuant to its published Privacy Act System of Records Notice. 

Disclosure: The provision of information for Form CG-6079 is voluntary; however, if you do not provide this information, 

the Coast Guard may be delayed in completing the processing of your request. Forms CG-6080 and CG_6081 are 

mandatory for Decision Makers. 

CG-6079 (06/20) PROVIDE FORM TO SUPERVISOR – COPY FOR EMPLOYEE/APPLICANT