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RRB Form HR - 142 

(10-18) 

REQUEST FOR REASONABLE ACCOMMODATION 

(Before completing this form, read Privacy Act Statement, Notices and Instructions on page 3) 

Section A. Employee/Applicant Information. (Complete Section A 1 13 only) 

1. Name 2. Position title 

3. Bureau/Office and Division (as applicable) 4. Telephone number 

5. RRB work address (or applicant’s home address) 6. Email address 

7. Please state the requested accommodation, if known. Be specific as possible-e.g. assistive technology, modified work schedule, 

etc.(attach additional page if necessary) 

8. Why is the accommodation needed? (attach additional page if necessary) 

9. Did you request an accommodation prior to completing this form? 

Yes No 

If so what date and to whom was the request made? 

10. Employee/Applicant signature 11. Date 

Section B. Management Actions 

1. Is medical documentation required? 

Yes No 

If no, provide comments. 

2. Does the documentation sufficiently 

support the request for accommodation? 

Yes No 

If no, provide comments. 

3. Summary of the “interactive process. (see instructions - attach additional documentation if necessary) 

(Page 2) RRB Form HR - 142 

(10-18) 

OMB APPROVAL NOT REQUIRED (<10 EXTERNAL RESPONSES ANNUALLY) 
 

 

 

 

 

 

 

 

 

Section B. Management Actions (cont’d) 

4.a. Approval and/or Recommendation of supervisor/manager 

Approved 

Recommend Approval 

Recommend Denial 

b. Comments 

c. Name d. Title 

e. Signature f. Date 

5.a. Office/Bureau Head 

Approved Recommend denial 

b. Comments 

c. Name d. Title 

e. Signature f. Date 

6.a. Board Member/Inspector General/AIGI/AIGA/Executive 

Committee Member 

Approved Denied 

b. Comments 

c. Name d. Title 

e. Signature f. Date 

Section C. Final Action (To be Completed by the Reasonable Accommodation Coordinator) 

1. Date Employee/Applicant received accommodation, if approved, or denial letter. 

2.a Comments 

b. Name c. Date 

d. Signature 

OMB APPROVAL NOT REQUIRED (<10 EXTERNAL RESPONSES ANNUALLY) 
 

 

 

 

 

 

 

 

 

 

 

 

 

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(Page 3) RRB Form HR - 142 

(10-18) 

PRIVACY ACT STATEMENT 

(Employee/Applicant: Read this information before submitting your request) 

The Railroad Retirement Board (RRB) is authorized to collect the information requested in this form by Section 501 of the Rehabilitation 

Act of 1973, as amended, 29 USC 791, and by Executive Order 13164. 

The information you provide will be used primarily to facilitate the processing of your request for reasonable accommodation and will 

also be used to compile statistical reports on the number and types of such requests received by the RRB. In addition, the RRB may be 

required to disclose information to medical personnel to meet a bona fide medical emergency; appropriate federal, state and local 

agencies in relation to civil criminal or regulatory investigations or prosecutions; when necessary to adjudicate a claim for benefits or to 

comply with a law governing the reporting of communicable diseases; to a federal agency or congressional office in connection with a 

decision in hiring, retention or the granting of security clearance; or to a federal agency, court or a party in litigation when the RRB is a 

party to the proceeding or served with a subpoena. 

Furnishing the requested information is voluntary* and will assist the RRB in processing your request. 

GENETIC INFORMATION NOTIFICATION ACT 

The Genetic Information and Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from 

requesting or requiring genetic information of employees or their family members, except as specifically allowed by this law. To comply 

with this law, we are asking that you not provide any genetic information when responding to a request for medical information. 

“Genetic Information” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family 

member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic 

information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family 

member receiving assistive reproductive services. 

NOTICE TO EMPLOYEE/APPLICANT 

*An individual does not need to complete this or any other specific form to initiate the interactive process. If your request for 

accommodation is denied, you have the right to file a complaint of discrimination with the RRB’s Office of Equal Opportunity (OEO). To 

file a complaint, contact OEO at (312) 751-4943 or (312) 751-4942. 

If your request is denied, you may also have the right to file a grievance under the collective bargaining agreement or the RRB’s 

administrative grievance procedure. Information about these procedures will be included in the denial notice, or you may contact the 

Reasonable Accommodation Coordinator (RAC) at RAC@rrb.gov or at (312) 751-4557. 

INSTRUCTIONS FOR COMPLETION OF RRB FORM G 142 

(Note: Additional sheets may be attached to the form for any questions needing more space for response.) 

Section A. 

1.	 Self-explanatory. 

2.	 Employee: provide information for employee’s current position. Applicant: provide information for the position applied for. 

3.	 Employee: Self-explanatory. 

4.	 Employee: show work number. Applicant: show daytime telephone number. 

5.	 Self-explanatory. 

6.	 Self-explanatory. 

7.	 Identify suggested accommodation, (if known) and alternative(s), where possible. 

8.	 Describe the current employment situation (or aspect of application process for which accommodation is requested) and state 

how the requested accommodation, if known, will eliminate barriers to full employment opportunity or the application process. 

Specifically, (for employees) how your condition affects your ability to perform your job or (for applicants) how it impacts your 

ability to complete the job application process. If the accommodation is not known, describe the barriers to full employment or 

the application process that you would like assistance in overcoming. 

9.	 Self-explanatory. 

10. Self-explanatory. If unable to sign (e.g., in hospital), supervisor or other party initiating request on behalf of individual may sign. 

11. Self-explanatory. 

Section B. 

1.	 Discuss whether the employee/applicant is required to provide medical documentation to support request. 

2.	 Discuss whether documentation provided is sufficient. If not, explain what more is required and why. 

3.	 Summarize contacts with employee/applicant about requested accommodation, documentation required, options, etc. 

4.	 Official who initiates processing must check appropriate box. If only recommending, forward to respective bureau/office head. 

5.	 Bureau/office head will check appropriate box and explain his/her decision in Comments. If recommending denial, forward to 

respective Executive Committee Member, AIGI, or AIGA as applicable, for decision. Before a denial is issued or an 

accommodation other than the one requested is granted, the decision-maker must consult with the RAC and provide written 

justification for the denial/alternative accommodation. The RAC shall consult with the OGC or OIG legal (for OIG 

employees/applicants) before issuing any denials. 

Section C. 

1. & 2. Self-explanatory. 

Please direct any questions about completion of this form to the
 

RRB’s Reasonable Accommodation Coordinator at rac@rrb.gov.
 

OMB APPROVAL NOT REQUIRED (<10 EXTERNAL RESPONSES ANNUALLY)