DEPARTMENT OF HOMELAND SECURITY 

U.S. Coast Guard 

MOBILITY PROGRAM DEVICE APPLICATION 

The loan of adaptive mobility devices allows temporary mobility assistance for visitors and US Coast Guard personnel recovering from surgery, illnesses, or 

injuries that affect their ability to move around a Coast Guard facility. Mobility devices enable qualified visitors access to the facility and provide personnel with 

temporary mobility issues the ability to return to work earlier than otherwise possible. Personnel requiring long-term mobility devices should request them through 

their supervisors via Coast Guard's Reasonable Accommodation procedures outlined in the Civil Rights Manual, COMDTINST M5350.4 (series) 

A. REQUESTING INDIVIDUAL: CG MEMBER APPLICANT VISITOR 

1. NAME (Last, First, Middle Initial) 2. ORGANIZATION/OFFICE LOCATION 

3. RANK/GRADE 4. TELEPHONE NUMBER 5. EMAIL ADDRESS 

6. REQUESTED ISSUANCE DATE 7. REQUESTED RETURN DATE 

I understand that this accommodation is for short-term usage. If I have a long-term or permanent mobility restriction due to an ongoing medical condition and 

require a long-term accommodation, I should request a device through the Coast Guard reasonable accommodation procedures. I understand that I am 

personally responsible for the issued government owned device and any ancillary items. I may be held liable for its loss or damage, unless otherwise relieved of 

responsibility by Board of Survey action. I understand that any violation of equipment use may forfeit the use of the device. I understand that the property is FOR 

OFFICIAL USE ONLY and it may not be transferred. The device must be returned to the issuing office. 

8. SIGNATURE 

PRINTED NAME 9. DATE 

B. SUPERVISOR/VISITOR SPONSOR 

10. NAME (Last, First, Middle Initial) 11. ORGANIZATION/OFFICE LOCATION 

12. RANK/GRADE 13. TELEPHONE NUMBER 14. EMAIL ADDRESS 

15. SIGNATURE 

PRINTED NAME 16. DATE 

C. ISSUING OFFICIAL 

17. ISSUE DATE 18. RETURN DUE DATE 

EXTENSION 

GRANTED 

19. EXTENDED DUE DATE 20. ISSUER INITIALS GRANTING EXTENSION 

21. SIGNATURE 

PRINTED NAME 22. DATE 

D. RETURNING OFFICIAL 

23. RETURN DATE 24. EMPLOYEE/VISITOR INITIALS 

25. SIGNATURE 

PRINTED NAME 26. DATE 

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 the loan of adaptive mobility devices by individuals with 

temporary mobility restrictions, 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 temporary loan of adaptive mobility devices. Additionally, the Coast Guard may share the information pursuant to its published Privacy Act 

System of Records Notice. 

Disclosure: The provision of information is voluntary; however, if you do not provide this information, the Coast Guard may be delayed in completing the 

processing of your application. 

CG-6260 (11/19) PROVIDE COPY TO EMPLOYEE/APPLICANT - COPY TO FILE