CONFIDENTIAL
ACOMMODATION REQUEST FORM

If you need help in completing this form, please contact the Disability Resource Center.

Section A: Customer Information

Name of the customer who will 
receive services:


Operating administration:
Date:
Federal employee?
?	Yes 
?	No
Position/Title:
Series and grade:
Office mailing address (no post office boxes please)
Room number/routing symbol:
Street address:


City:


State:
Zip:
Phone (Voice):

Phone (TTY):
Fax:
Employee’s E-mail:

Supervisor’s E-mail:

Supervisor’s name (for job accommodation requests):


Phone number:
Name of person completing form (if different than the 
customer):

Phone number:

Relationship to customer:
Disability Information (Check all that apply to the request for service):
?	Visual
?	Hearing
?	Speech
?	Learning 
?	Cognitive/Developmental
?	Dexterity
?	Mobility
?	Psychiatric
?	Hidden disability
?	Temporary
?	Other:

The Services are for:
?	Myself
?	Visitor on official business
?	My employee
?	Job applicant
?	My organization
?	Other:

Is this a Worker’s Compensation Claim? 
?	Yes     Claim number:
?	No

Section B: Job Accommodation Information

Briefly explain the primary limitations that you are experiencing in performing your job.


What accommodation(s) are you requesting?  
(If you have a particular accommodation in mind, please describe it and include specific information such as the 
brand or model name.)



?	Sign language interpreter services (please complete an interpreter request form)
?	Computer modification (adaptive keyboard, alternative mouse, voice input, screen reader, screen magnifier, 
Braille display, etc.)

?	Communication technologies (TTY, PC TTY, telephone amplifier, signaling devices, assistive listening 
device, telephone headset, etc.)

?	Workspace modifications (non-structural changes to furniture or storage)
?	Services (readers, note takers, personal assistance services)
?	Media in alternative formats (Braille, large print, ASCII, audio, captioning)
?	Other:________________________________________________________
?	Not sure what I need
What date did you first discuss this request with your supervisor?

_____/_____/______      0  Have not discussed to date
Do you currently use accommodations or assistive technologies? 
?	Yes     If yes, please describe:
?	No

What’s Next?
Thank you for taking time to complete this form.  The DRC “Analyst On-Call” will review your information and 
forward your request to a Disability Resource Analyst who will contact you promptly.  The analyst will discuss 
some or all of the following information with you prior to providing a reasonable accommodation. 
 

?	What are your job functions (provide a copy of your position description)?

?	How will the accommodation help you on your job?

?	What is the setting in which the accommodation will be used?

?	Medical documentation might be required.


Feel free to contact us if you have any questions.

Reasonable accommodations create equal opportunities in the workplace.


Revised March 22, 2005		2
M-14.4, Room 2110
400 7th Street SW
Washington, DC  20590
Voice: (202) 493-0625, TTY: (202) 366-5273, Fax: (202) 366-3571
E-mail: drc@dot.gov	    Web Site:  www.drc.dot.gov

Revised March 22, 2005