DEPARTMENT OF HOMELAND SECURITY 

U.S. Coast Guard 

ACKNOWLEDGEMENT OF REASONABLE ACCOMMODATION OR 

PERSONAL ASSISTANCE SERVICE REQUEST 

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. 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. 

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. DATE OF REQUEST 8. METHOD OF REQUEST 

CG-6079 PROVIDED 

WRITTEN/EMAIL REQUEST 

VERBAL REQUEST 

9. REQUESTED BY 

REPRESENTATIVE 

APPLICANT 

EMPLOYEE 

10. REQUEST TYPE 

PERSONAL ASSISTANCE SERVICE 

REASONABLE ACCOMMODATION 

11. REQUEST 

12. EXPEDITED PROCESSING REQUESTED? 

NO 

YES (Explain in block 13) 

13. EMPLOYEE/APPLICANT REASON FOR REQUESTING EXPEDITED PROCESSING 

14. EMPLOYEE/APPLICANT MEDICAL CONDITION 

15. MEDICAL DOCUMENTATION REQUESTED? 

NO 

YES 

Under the Rehabilitation Act, the USCG is permitted to request medical information in support of a request 

for reasonable accommodation where the disability and/or the need for reasonable accommodation are 

not obvious or otherwise already known. In these instances, the USCG may require reasonable 

documentation necessary to establish that the individual has a disability and needs accommodation. Refer 

to the Coast Guard Civil Rights Manual or contact your servicing Civil Rights Service Provider for additional 

information and guidance. 

16. TEMPORARY/INTERIM ACCOMMODATION OR PERSONAL ASSISTANCE SERVICE PROVIDED (If none, state “None”) 

17. INTERIM DATES 

THRU 

Temporary/interim accommodations may be granted while awaiting any medical documentation or additional 

information to make a final decision. Granting a temporary accommodation does not guarantee that a 

permanent accommodation will be granted or that the same accommodation will be granted in the final 

decision. 

18. DECISION MAKER'S SIGNATURE 19. DATE 

CG-6080 (06/20) PROVIDE TO EMPLOYEE/APPLICANT - COPY TO FILE 
 

 

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-6080 (06/20) PROVIDE TO EMPLOYEE/APPLICANT - COPY TO FILE