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Reasonable Accommodation Request

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Form13661 (Rev. 7-2005) Catalog Number 39619XDepartment of the Treasury - Internal Revenue ServiceReasonable Accommodation RequestPart IWritten Reasonable Accommodation RequestTo be completed by applicant for employment, employee, or personnelmanagement specialist to document Reasonable Accommodation IIDeciding Official DocumentationTo be completed by Deciding Official for use in information trackingpurposes. Part II, Items 5, 6, and 7, may be provided to Health CarePractitioner, Social Worker, or Rehabilitation Counselor as supplementalinformation. (Internal Use Only)Part IIIMedical DocumentationTo be completed by Health Care Practitioner, Social Worker, or IVDenial of Reasonable Accommodation RequestTo be completed by Deciding Official to document the denial of reasonableaccommodation.

Briefly, describe the disability/medical condition requiring accommodation. 8. Describe the requested reasonable accommodation. 9. Check the appropriate box below (may check more than one box) and explain how the reasonable accommodation will assist the applicant/employee in: Application process Performing Job Functions or

  Process, Request, Reasonable, Accommodation, Reasonable accommodation request

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