CUI//SP-PERS

FEDERAL MEDIATION AND CONCILIATION SERVICE

250 E Street, SW

Washington, D.C. 20427

Reasonable Accommodation Request Form

CONFIDENTIAL

Please complete this form if you have a physical or mental health disability and need a reasonable accommodation to 

perform the essential functions of your position or to participate in the hiring process. Should you need any help completing

this form, or if you have any questions about this form or FMCS’s reasonable accommodation policy, please speak to the 

Reasonable Accommodation Coordinator (RAC) at (202) 606-5465. This form should be returned directly to the RAC, 250 E 

Street, SW, Washington, DC 20427, Attention: Natalie C. Samuels OR E-mail to FMCSMedicalInfo@fmcs.gov . FOR 

CURRENT EMPLOYEES, THIS FORM SHOULD NOT BE RETURNED TO YOUR MANAGER OR TO ANYONE AT YOUR 

LOCATION.

EMPLOYEE/APPLICANT NAME: 

DEPARTMENT: 

LOCATION:

POSITION: 

1. Please describe the accommodation(s) you are requesting. If there is more than one accommodation that 

you believe will meet your needs, please describe all possible accommodations.

2. Please describe your medical condition and the reason(s) why you are requesting an accommodation. For 

current employees, include a description of the essential functions of your job that you currently are 

unable to perform, and explain how the requested accommodation(s) will enable you to perform those 

essential functions of your job.
CUI//SP-PERS

FEDERAL MEDIATION AND CONCILIATION SERVICE

250 E Street, SW

Washington, D.C. 20427

Employee/Applicant Name:

3. For how long the requested accommodation(s) will be needed. 

4. Please attach to this form any documentation that you believe supports your need for the requested 

reasonable accommodation. Please also provide any other information that you believe is relevant to your 

request.

I certify that the information contained on this form and submitted with this form is true and correct.

Signature Date

Privacy Act Statement. 29 U.S.C. 172, et seq. The Rehabilitation Act of 1973, United States Code - 29 U.S.C. § 791; The 

Americans with Disabilities Act of 1990, 42 U.S.C. § 12101; Title VII of the Civil Rights Act, 42 U.S.C. § 2000e-16; the Family 

and Medical Leave Act of 1993, 29 U.S.C. § 2601; 40 U.S.C. § 3173; Executive Order - E.O. 13164 (July 28, 2000); E.O. 13548 

(July 26, 2010); E.O. 14042 (September 9, 2021); and E.O. 14043 (September 9, 2021) authorize the FMCS to collect this 

information. The primary use of the information on this form is to facilitate the reasonable accommodation process. Additional 

disclosures of the information on this report may be made: (1) to a Federal, State, or local law enforcement agency if FMCS 

becomes aware of a violation or potential violation of law or regulation; (2) to a court or party in a court or Federal 

administrative proceeding if the Government is a party or in order to comply with a judge-issued subpoena; (3) to the National 

Archives and Records Administration or the General Services Administration in record management inspections; (4) to the 

Office of Management and Budget during legislative coordination on private relief legislation; and (5) in a judicial or 

administrative proceeding if the information is relevant to the subject matter; (6) to the Equal Employment Opportunity 

Commission through their mandatory reports. This confidential information will not be disclosed to any requesting person unless 

authorized by law. Failure to provide the requested information could result in FMCS’s delay or inability to facilitate the 

reasonable accommodation process
CUI//SP-PERS

FEDERAL MEDIATION AND CONCILIATION SERVICE

250 E Street, SW

Washington, D.C. 20427

CERTIFICATION OF HEALTH CARE PROVIDER 

FOR REASONABLE ACCOMMODATION

Patient’s Name:

Date Condition Commenced:

Probable Duration of Condition: 

This certification will be used for the purpose of assessing whether your patient has a disability that 

would benefit from a reasonable accommodation within the workplace. Please base your assessment 

on your patient’s present abilities or limitations in performing the essential functions of his/her current 

position as described to you.

1. Does your patient have a disability?1  Yes  No

2. If you answered “yes” to question #1, is your patient able to perform  Yes  No 

each of the essential job functions described without reasonable

accommodation(s)?

3. If you answered “no” to question #2, would your patient be able to perform  Yes  No 

each of the essential job functions described with reasonable

accommodation(s)?

4. If you answered “yes” to question #3, please provide the following information: a) state which 

essential function(s) of the job require an accommodation; b) for each such essential function, any 

recommendations you have for reasonable accommodation(s). If there is more than one 

recommended accommodation, please describe all possible accommodations; c) explain why the 

disability requires this accommodation to allow the employee to perform the essential function(s).

1 A disability is a condition that imposes a substantial limitation on a major life activity. By way of example, “major life activities” include, but are 

not limited to, standing, sitting, walking, lifting, talking, interacting with others, eating, breathing, hearing, seeing, speaking, working, and 

learning.

Disability also means a physical disability, infirmity, malformation or disfigurement which is caused by bodily injury, birth defect or 

illness including epilepsy and other seizure disorders, and which shall include, but not be limited to, any degree of paralysis, amputation, lack 

of physical coordination, blindness or visual impediment, deafness or hearing impediment, muteness or speech impediment or physical 

reliance on a service or guide dog, wheelchair, or other remedial appliance or device, or any mental, psychological or developmental disability 

resulting from anatomical, psychological, physiological or neurological conditions which prevents the normal exercise of any bodily or mental 

functions or is demonstrable, medically or psychologically, by accepted clinical or laboratory diagnostic techniques. Disability shall also mean 

AIDS or HIV infection.
CUI//SP-PERS

FEDERAL MEDIATION AND CONCILIATION SERVICE

250 E Street, SW

Washington, D.C. 20427

Patient/Employee’s Name:

Print or type clearly the name and address of the Health Care Provider completing this form: 

Name:

Address:

Telephone: 

Facsimile:

E-mail Address:

Signature of Health Care Provider Date

This form should be returned directly to the RAC, 250 E Street, SW, Washington, DC 20427, Attention: 

Natalie C. Samuels OR fax to (202) 827-2355. You can E-Mail the form to 

FMCSMedicalInfo@FMCS.GOV . FOR CURRENT EMPLOYEES, THIS FORM SHOULD NOT BE 

RETURNED TO YOUR MANAGER OR TO ANYONE AT YOUR LOCATION.