Fillable (REV. MARCH, 2013) DAO 215-10 REQUEST FOR REASONABLE (Depatment of Commerce)

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(REV. MARCH, 2013) DAO 215-10 REQUEST FOR REASONABLE (Depatment of Commerce)

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FORM CD-575 U.S. DEPARTMENT OF COMMERCE
(REV. MARCH, 2013)
DAO 215-10
REQUEST FOR REASONABLE ACCOMMODATION
Please submit this form as soon as possible to the servicing Reasonable Accommodations Coordinator (RAC).
This form is used for record-keeping and reporting purposes. In addition, the information provided will be used to
determine whether reasonable accommodation is needed and, if so, what accommodation will be effective and
appropriate. This form will be maintained separately from the requestor’s personnel file, and it is a confidential
document.
PART A: EMPLOYEE REQUEST AND CERTIFICATION
Instructions: This section should be completed by an employee or applicant who believes he or she has a disability
and who wishes to request reasonable accommodation (the requestor). Please attach a separate sheet if more space
is needed. The Reasonable Accommodations Coordinator (RAC) should complete this section of the form for the
requestor if the requestor requires assistance or otherwise does not complete the form. Requests for
accommodation will be addressed promptly even if the requestor does not complete this form.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by
GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,
except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic
information when responding to this form. “Genetic information,” as defined by GINA, includes an individual’s family
medical history, the results of an individual’s or family member's genetic tests, the fact that an individual or an
individual's family member sought or received genetic services, and genetic information of a fetus carried by an
individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving
assistive reproductive services.
1. Requestor’s name:
2. Requestor’s telephone number and e-mail address:
3. If the requestor is a current employee of the Department:
3.a. Requestor’s title, series, and grade:
3.b. Requestor’s bureau (or O/S) and division:
3.c. Name and title of requestor’s immediate supervisor:
3.d. Telephone number and e-mail address of Requestor’s immediate supervisor:
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4.a. Name of the person the Requestor contacted initially about this request for reasonable accommodation:
4.b. Role of that person (check all that apply):
Immediate supervisor;
Another supervisor in the requestor’s chain of
command;
Reasonable Accommodation Coordinator (RAC);
HR Specialist;
EEO Specialist; and/or
Other:
5. Date of initial reasonable accommodation request:
6. Functional limitations and/or workplace barriers for which accommodation is needed. (Note: The response to this
item need not
identify the requestor’s medical impairment or condition.)
7. Specific accommodation(s) the requestor is seeking. (Note: An employee must be able to perform the essential
functions of the employee’s position, either with or without accommodation.)
8. Check any of the below categories that apply to the request. (Note: These categories provide examples of
frequently-requested accommodations. This is not an exhaustive list.)
Reconfigured work space;
Removal of an architectural barrier;
Acquisition or modification of equipment, furniture, or devices;
Assistive Devices (Non-CAP);
CAP request (Computer or Electronic Office Equipment);
CAP request (Computer Software);
Materials in alternative formats;
Adjustment or modification of examinations, training materials, or policies;
Readers, interpreters (such as Sign Language interpreters), or captioning;
Job restructuring;
Part-time or modified work schedules (such as an Alternate Work Schedule);
Telework;
Parking;
Scooter;
Reassignment to a vacant, funded position; and/or
Other:
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9. Reasonable accommodation is needed to (check all that apply):
Participate in the application process;
Perform the essential functions of the requestor’s job;
Gain access to the workplace; and/or
Enjoy equal benefits and privileges of employment as are enjoyed by similarly-situated
employees without disabilities (e.g., training, employee assistance programs, credit unions,
cafeterias, lounges, gymnasiums, auditoriums, parties or other social functions).
10. Length of time the required accommodation(s) will be needed:
11. Explain any time-sensitive issues related to the request. ________________________________________
Note: If a disability and/or need for reasonable accommodation is not obvious and not already on file with the
Department, the Department has a right to request medical documentation to substantiate the disability and the
requested accommodation. The RAC will use any medical documentation submitted to make determinations
regarding whether the requestor has a covered disability, whether the requestor needs an accommodation because
of that disability, and what accommodation(s) would be effective and appropriate. The RAC may work with a medical
consultant, such as medical professionals from Federal Occupational Health (FOH) and the Department’s health units,
if necessary, in making these determinations. The RAC will not share any medical documentation the requestor
submits with any individual who does not have an official need to know. Ordinarily, the deciding official will not
need to know what the requestor’s underlying medical impairment is. Rather, the deciding official will make his or
her decision based on the RAC’s recommendations regarding what the functional limitations and workplace barriers
are, whether accommodation is appropriate, and what accommodation(s) would be effective.
CERTIFICATION AND CONSENT BY EMPLOYEE OR APPLICANT
This certification and consent is requested to ensure that Department officials have accurate information upon which
to assess the Requestor’s reasonable accommodation request.
I hereby certify that all statements made above are true to the best of my knowledge and belief. I hereby give
permission for the release of information about my request and my medical condition(s) to agency officials with an
official need to know and, if necessary, medical consultants, such as medical professionals from Federal Occupational
Health (FOH) or the Department’s health units.
Requestor’s signature Date Requestor’s daytime telephone number
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signature
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PART B: ACCOMMODATION REPORT
Items 1 through 3 are to be completed by the RAC and provided to the deciding official.
1. Name individual requesting reasonable accommodation (requestor):
2. Title, bureau, and division of Requestor (if the Requestor is a current employee of the Department):
3. Accommodation(s) requested:
Items 4 through 12 are to be completed by deciding official (i.e., Supervisor, Office or Division Director, HR Specialist)
with advice from the RAC and the Office of the General Counsel. The deciding official must complete and submit
this form to the RAC as soon as possible after final determination of the reasonable accommodation request.
4. Name and title of deciding official:
5. Date reasonable accommodation request was referred to deciding official:
6. Interim measures provided, if any:
7. Date reasonable accommodation approved or denied:
8. If time frames outlined in DAO 215-10, Reasonable Accommodation for Employees or Applicants with Disabilities
were not met, explain reason(s):
9. Decision on reasonable accommodation request:
Approved Denied
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10. If approved, identify the accommodation(s) granted:
11. If denied, attach a copy of the written denial letter or memorandum that identifies the reason (see
Section 12 of DAO 215-10).
12. Sources of technical assistance, if any, consulted in trying to identify possible reasonable accommodations (e.g.,
Federal Occupational Health (FOH), Job Accommodation Network (JAN), disability organization). (Note: The response
to this item should not
identify legal advice provided by the Office of the General Counsel.)
CERTIFICATION OF DECIDING OFFICIAL
I hereby certify that all statements made above are true to the best of my knowledge and belief.
Deciding official’s signature Date Daytime telephone number and e-mail Address
For more information on how to contact the servicing RAC, please see the Office of Civil Rights website:
http://www.osec.doc.gov/ocr/CivilRights/Disability/ReasonableAccommodation.html or contact:
Office of Civil Rights, U.S. Department of Commerce
14th Street and Constitution Avenue, NW, Room 6012
Washington, D.C. 20230
Attention: Disability Policy Advisor
[202-482-0625]
If the requestor is not satisfied with this decision, the requestor may request reconsideration from the person who
issued the decision (the deciding official) or to a higher-level supervisor in deciding official’s chain of command. Any
request for reconsideration must be received no later than 30 business days from the date the requestor received the
decision. Any requestor seeking reconsideration must follow the process outlined in DAO 215-10, including
submitting with the reconsideration request a copy of the decision issued to the requestor and any additional
information or arguments the requestor wishes to submit.
To initiate an EEO complaint, the requestor must bring the matter to the attention of an EEO counselor within 45
calendar days of the requestor’s receipt of the decision. To do so, or for additional information, the requestor should
contact the Office of Civil Rights at 202-482-5691. Pursuing reconsideration of a denial will not toll or extend
mandatory time limits for initiating EEO complaints or other grievance procedures.
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Page 6 of 7
Privacy Act Advisory Statement
The Privacy Act of 1974 requires that you be given certain information about this form. The authority for the request
for Reasonable Accommodation form is derived from the Rehabilitation Act of 1973, as amended, which stipulates
that Federal agencies must provide reasonable accommodations to qualified individuals with disabilities. 29 U.S.C.
Section 791; 29 C.F.R. Part 1614; see also 20 C.F.R. part 1630. Further, Executive Order 13164 mandates that Federal
agencies have written procedures for providing reasonable accommodation and maintain records in order to monitor
the effectiveness of the procedures. Completion of this form is voluntary, however, no accommodation may be given
to a qualified individual without this written information. The Director, Office of Civil Rights, shall maintain a record of
all accommodation requests, which will be utilized to determine the efficacy and consistency of the reasonable
accommodation procedures process and be compiled for reports to the Equal Employment Opportunity Commission
(EEOC); these records are subject to periodic review by the EEOC, at its request, to ensure compliance. Other routine
uses are listed below.
Routine Uses
1. In the event that a system of records maintained by the Department to carry out its functions indicates a violation
or potential violation of law or contract, whether civil, criminal, or regulatory in nature, and whether arising by
general statute or particular program statute or contract, or rule, regulation, or order issued pursuant thereto, or the
necessity to protect an interest of the Department, the relevant records in the system of records may be referred to
the appropriate agency, whether Federal, state, local, or foreign, charged with the responsibility of investigating or
prosecuting such violation or charged with enforcing or implementing the statute or contract, or rule, regulation, or
order issued pursuant thereto, or protecting the interest of the Department.
2. A record from this system of records may be disclosed to a Federal, state, or local agency maintaining civil,
criminal, or other relevant enforcement information, or other pertinent information, such as current licenses, if
necessary to obtain information relevant to a Department decision concerning the assignment, hiring, or retention of
an individual, the issuance of a license, grant or other benefit.
3. A record from this system of records may be disclosed to a Federal, state, local or international agency, in response
to its request, in connection with the assignment, hiring, or retention of an individual, the issuance of a security
clearance, the reporting of an investigation of the individual, the letting of a contract, or the issuance of a license,
grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the
requesting agency’s decision on the matter.
4. A record from this system of records may be disclosed in the course of presenting evidence to a court, magistrate,
or administrative tribunal, including disclosures to opposing counsel in the course of settlement negotiations.
5. A record in this system of records may be disclosed to a Member of Congress submitting a request involving an
individual when the individual has requested assistance from the Member with respect to the subject matter of the
record.
6. A record in this system of records may be disclosed to the Department of Justice in connection with determining
whether disclosure thereof is required by the Freedom of Information Act (5 U.S.C. 552).
7. A record in this system of records may be disclosed to a contractor of the Department having need for the
information in the performance of a contract, but not operating a system of records within the meaning of 5 U.S.C.
552a(m).
8. A record in this system may be disclosed to the Office of Personnel Management for personnel research purposes;
as a data source for management information; for the production of summary descriptive statistics and analytical
studies in support of the function for which the records are collected and maintained; or for related manpower
studies.
9. A record from this system of records may be disclosed to the Administrator, General Services Administration (GSA),
or his designee, during an inspection of records conducted by GSA as part of that agency’s responsibility to
recommend improvements in records management practices and programs under authority of 44 U.S.C. 2904 and
2906. Such disclosure shall be made in accordance with the GSA regulations governing inspection of records for this
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purpose, and any other relevant (i.e. GSA or Commerce) directive. Such disclosure shall not be used to make
determinations about individuals.
10. A record in this system of records may be disclosed to any source from which additional information is requested
in the course of processing a grievance to the extent necessary to identify the individual, inform the source of the
purposes(s) of the request, and identify the type of information requested.
11. A record in this system of records may be disclosed to officials of the Office of Personnel Management, Merit
Systems Protection Board, including the Office of the Special Counsel, the Federal Labor Relations Authority and its
General Counsel, or the Equal Employment Opportunity Commission, the Department of State, or the Department of
Labor when requested in performance of their authorized duties.
12. A record in this system of records may be disclosed in response to a request for discovery or for appearance of a
witness, information that is relevant to the subject matter involved in a pending judicial or administrative proceeding.
13. A record in this system of records may be disclosed to officials or labor organizations reorganized under the Civil
Service Reform Act when relevant and necessary to their duties of exclusive representation concerning personnel
policies, practices, and matters affecting work conditions.
14. A record in this system of records may be disclosed to commercial contractors (dept collection agencies) for the
purpose of collecting delinquent debts authorized by the Debt Collection Act (31 U.S.C. 3718).
15. A record in this system of records may be disclosed to Senior State Department officials at U.S. Embassies,
including the Ambassador, Deputy Chief of Mission, Administrative Counselor and Human Resource Officers, for
matters relating to employment or security issues pertaining to Department of Commerce employees working in U.S.
Embassies or facilities overseas.16) A record in this system of records may be disclosed to the U.S. Coast Guard for
National Oceanic and Atmospheric Administration wage marine employees for the purpose of complying with
the requirements of the Drug and Alcohol-Free Workplace Program. (17) A record in this system of records may
be disclosed to the U.S. Department of Transportation for employees in transportation positions for the purpose
of complying with the requirements of the Omnibus Transportation Employee Testing Act of 1991 and 49 CFR
Part 40.
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Completed 30 June 2021

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