U.S. DEPARTMENT OF

HOMELAND SECURITY

U.S. COAST GUARD

CG-xxxx (Rev. xx-xx)

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 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 16. DATE

C. ISSUING OFFICIAL

17. ISSUE DATE 18. RETURN DUE DATE

19. TYPED/PRINTED NAME AND SIGNATURE 20. DATE

 EXTENSION GRANTED

21. EXTENDED DUE DATE 22. ISSUER INITIALS GRANTING EXTENSION

D. RETURNING OFFICIAL

23. RETURN DATE 24. EMPLOYEE/VISITOR INITIALS

25. TYPED/PRINTED NAME AND SIGNATURE 26. DATE

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-xxxx (Rev. xx-xx)

PROVIDE COPY 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 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.