Form CD-575 Reasonable Accommodations for Employees and Applicants w

EXHIBIT 1 DAO 215-10

CD FORM 575

OMB Control No. 0690-0022

REASONABLE ACCOMMODATION FOR APPLICANTS AND EMPLOYEES

WITH DISABILITIES

PART A: CONFIRMATION OF REQUEST

To Be Completed by Applicant or Employee

___________________________ _________________________________________

Applicant's or Employee's Name Applicant's or Employee's Telephone No.

Today's Date ____________________ ______________________________________

Employee's Office

Initial Date of Request ___________________

1. ACCOMMODATION REQUESTED. (Be as specific as possible, e.g., adaptive equipment, reader, interpreter or explain what is needed for you to perform the job.)

2. REASON FOR REQUEST. (Explain how the accommodation would assist an employee to perform tasks or how it would assist an applicant in the selection process.)

3. MEDICAL DOCUMENTATION. If a disability and/or need for reasonable accommodation is not obvious or already on file with the Department, the Department has a right to request medical documentation to substantiate the disability and the requested accommodation. This information should be attached, unless it has already been provided.

If accommodation is time sensitive, please explain:

Submitted by___________________________________________

(Applicant or Employee Signature)

NOTE TO APPLICANTS AND EMPLOYEES:

If for any reason, you are dissatisfied with the decision on your request for accommodation, you may file a complaint of EEO discrimination. For more information, contact an EEO Officer.

Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the PRA unless that collection of information displays a currently valid OMB control number.

EXHIBIT 1

CD FORM 575

OMB Control No. 0690-0022

REASONABLE ACCOMMODATION FOR APPLICANTS AND EMPLOYEES

WITH DISABILITIES

PART B: ACCOMMODATION REPORT

To Be Completed by Deciding Official

Name of Individual Requesting Reasonable Accommodation: ________________________

Office of Requesting Individual: _____________________________________

1. Reasonable accommodation: (check one)

1. Approved

   1. Denied (If denied, attach copy of the written denial letter/memo stating reason - See Section 5.06, of DAO 215-10, Reasonable Accommodation Procedures).

2. Date reasonable accommodation requested: _________________________

Who received request: ____________________________________

3. Date reasonable accommodation request referred to deciding official (i.e., supervisor, Office Director, Personnel Management Specialist): ________________

Name and Title of deciding official: _____________________________________

4. Date reasonable accommodation approved or denied: ______________________

5. Date reasonable accommodation provided (if different from date approved): __________

6. If time frames outlined in the DAO 215-10, Reasonable Accommodation Procedures, were not met, please explain:

7. Job held or desired by individual requesting reasonable accommodation (including occupational series, grade level, and office):

8. Reasonable accommodation needed for: (check one)

2. Application Process

3. Performing Job Functions or Accessing the Work Environment

Accessing a Benefit or Privilege of Employment (e.g., attending a training program

or social event)

EXHIBIT 1 - 3 - DAO 215-10

CD FORM 575

OMB Control No. 0690-0022

9. Type(s) of reasonable accommodation requested (e.g., adaptive equipment, staff assistant, removal of architectural barrier):

10. Type(s) of reasonable accommodation provided (if different from what was requested):

11. Was medical information required to process this request? If yes, explain.

12. Sources of technical assistance, if any, consulted in trying to identify possible reasonable accommodations (e.g., Job Accommodation Network, disability organization, Disability Program Manager):

13. Comments:

Submitted by: ______________________________________ Phone: ________________

Title_____________________________________

Attach copies of all documents obtained or developed in processing this report form and submit to your servicing EEO or HR specialist.

Department of Commerce

Office of Civil Rights

14^th Street and Constitution Avenue NW Room 6012

Washington, DC 20230

Attention: Disability Program Manager.

NOTE TO APPLICANTS AND EMPLOYEES:

If for any reason, you are dissatisfied with the decision on your request for accommodation, you may file a complaint of EEO discrimination. For more information, contact an EEO Officer.