UNCLASSIFIED//FOR OFFICIAL USE ONLY
UNCLASSIFIED//FOR OFFICIAL USE ONLY
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IBWC Form 392 (EEO)
05/2015 Previous Editions are Obsolete
RemarksLog Number
REQUEST FOR REASONABLE ACCOMMODATION
Applicant or Employee's Name Request Date
Applicant or Employee's Phone Applicant or Employee's Office
Accommodation Requested (if known. Be specific as possible, e.g. adaptive equipment, reader, interpreter, schedule change)
Reason for Request
EEO Staff Only
Form must be returned to EEO Manager
PRIVACY ACT STATEMENT
The Rehabilitation Act of 1973, 29 U.S.C. section 791, and Executive Order 13164 authorize collection of this information. The
primary use of this information is to consider, decide, and implement requests for reasonable accommodation. Additional
disclosures of the information may be: To medical personnel to meet a bona fide medical emergency; to another Federal agency,
a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency when the
Government is a party to the judicial or administrative proceeding; to a congressional office from the record of an individual in
response to an inquiry from the congressional office made at the request of the individual; and to an authorized appeal grievance
examiner, formal complaints examiner, administrative judge, equal employment opportunity investigator, arbitrator or other duly
authorized official engaged in investigation or settlement of a grievance, complaint or appeal filed by an employee.
If Accommodation is Time Sensitive, Please Explain
