Request for Accommodation in Communication Method

Other Accommodation Information Entry Screen

Other Accommodation Information Entry Screen (concluded)

Verification/Summary Screen

Confirmation Screen

Other Accommod
dation Histo
ory Summary Screen
n

Other Accommodation History Summary Screen (Other Accommodation Requests After
May 2011 Release)

Intranet (CSR) Screens
S
(Query Mode)
Client Authenticattion Screen

Special Notice Option Selection Screen

Other Accommod
dation Histo
ory Summary Screen
n

Other Accommodation History Summary Screen (Other Accommodation
Requests After May 2011 Release)

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 504 of the Rehabilitation Act of 1973 allows us to collect this information. Furnishing
us this information is voluntary. However, failing to provide all or part of the information may
prevent us from providing you with the accommodation you are requesting.
We will use the information to process your request for reasonable accommodation. We may
also share your information for the following purposes, called routine uses:
1. To contractors and Federal, State, or local agencies, as necessary, to assist Social Security
Administration (SSA) in providing accommodations to members of the public seeking
access to our programs and activities, in compliance with Section 504 of the
Rehabilitation Act of 1973. We will disclose information under this routine use pursuant
only to a written agreement between SSA and that contractor or agency; and
2. To Federal, State, or local agencies (or agents on their behalf) for providing
accommodations to members of the public in compliance with Section 504 of the
Rehabilitation Act of 1973, when that agency is administering cash or non-cash income
maintenance or health maintenance programs (including programs under the Social
Security Act).
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0378, entitled Requests for Accommodation from Members of the Public.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia.bluebook.