UNCLASSIFIED//FOR OFFICIAL USE ONLY
UNCLASSIFIED//FOR OFFICIAL USE ONLY
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IBWC Form 393 (EEO)
05/2015 Previous Editions are Obsolete
REASONABLE ACCOMMODATION INFORMATION REPORTING FORM
Requestor's Name Requestor's Office
Reasonable Accommodation (check one)
Approved (Whether it is what was originally requested or an alternative)
Denied (Attach copy of the “Resolution of Reasonable Accommodation Request” form)
Date of Original Request Person Receiving Original Request
Date Request Referred to Disability Program Manager (If applicable)
Date Accommodation Approved or Denied Date Reasonable Accomodation Made (if different from approval date)
If Time Frames Outlined in Procedures Were Not Met, Explain
Position Held or Desired by Individual Requesting Reasonable Accommodation (incl. occupational series, grade, office)
Reasonable Accommodation Required for (check one)
Application Process
Performing Job Functions or Accessing the Work Environment
Accessing a Benefit or Privilege of Employment (e.g. attending a training program or social event)
Type(s) of Reasonable Accommodation Requested (e.g. adaptive equipment, staff assistance, removal of architectural barrier)
Type(s) of Reasonable Accommodation Provided (if different form requested)
Attach Copies of All Document Developed or Obtained in Processing This Request
Determined that individual: (check one)
does have a disability as defined by the Rehabilitation Act
no disability determination made
does not have a disability as defined by the Rehabilitation Act
Cost of Accommodation Provided
