DEPARTMENT OF HOMELAND SECURITY 

U.S. Coast Guard 

REASONABLE ACCOMMODATION DECISION OR PERSONAL ASSISTANCE SERVICE 

DECISION AND REPORTING FORM 

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. REQUEST 

9. EMPLOYEE/APPLICANT REASON(S) FOR REQUEST 

10. MEDICAL DOCUMENTATION REQUESTED? YES NO 

11. DATE MEDICAL DOCUMENTATION REQUESTED 12. DATE MEDICAL DOCUMENTATION RECEIVED 

Rehabilitation Counselor 

USPHS Physician 

Civil Rights Service Provider 

Human Resources/Employee Relations 

Department of Transportation Disability Resource Center 

https://www.transportation.gov/drc 

Computer/Electronics Accommodations Program 

www.cap.mil 

Job Accommodation Network 

askjan.org 

Other 

13. RESOURCES AVAILABLE FOR CONSULTATION 

APPROVAL (An approval is when the requestor's original request has been granted in full) 

14. DESCRIPTION OF WHAT WAS APPROVED 

15. DECISION MAKER’S NAME (Last, First, Middle Initial) 16. ORGANIZATION/OFFICE LOCATION 

17. APPROVAL SIGNATURE 18. APPROVAL DATE 

19. COST 20. PROCUREMENT REQUEST NUMBER (Use the correct 

accommodation object class code) 

21. DATE PROCUREMENT BEGAN 22. DATE PROCURED 

CG-6081 (06/20) PROVIDE TO EMPLOYEE/APPLICANT - COPY TO CIVIL RIGHTS SERVICE PROVIDER - COPY TO FILE 
 

   

 

DENIAL (A denial is when any of the requestor's original request has not been granted) 

22. REASON FOR DENIAL 

23. ALTERNATE OFFERED 

24. ALTERNATE PROVIDED (If the alternate must be procured, please use boxes 19-22, above) 

25. DECISION MAKER'S NAME (Last, First, Middle Initial) 26. ORGANIZATION/OFFICE LOCATION 

27. DECISION MAKER'S SIGNATURE 28. DENIAL DATE 

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

• ask the decision maker, in writing within five (5) business days of receiving the decision to deny, to reconsider the

denial and provide additional supporting information; 

• if the decision maker does not reverse the decision within five (5) business days, the individual may appeal the 

decision, in writing, to the PWDP Manager within ten (10) business days of receiving the decision. The appeal shall be 

decided by the PWDP Manager. A response to the appeal will be issued to the individual within ten (10) business days. 

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 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. 

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-6081 (06/20) PROVIDE TO EMPLOYEE/APPLICANT - COPY TO CIVIL RIGHTS SERVICE PROVIDER - COPY TO FILE