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Reasonable Accommodation Request - IRS Careers

Form13661 (Rev. 7-2005) Catalog Number 39619 XDepartment 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 IIIM edical 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. (Internal Use Only) Accommodation RequestPart I Written Reasonable Accommodation RequestTo be completed by applicant, employee, or personnel or management official1. Applicant/EmployeeLast NameFirst NameSEID OccupationalSeriesGrade3.

Reasonable Accommodation Request Part III – Medical Documentation To be completed by a Health Care Practitioner, Social Worker, or Rehabilitation Counselor Name of Applicant/Employee Instructions We have been requested to consider a reasonable accommodation for the individual named above. An accommodation is a logical

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