(Must complete numbers 1-4; complete number 5, if applies)

1. Name of Individual requesting reasonable accommodation:
    
    
2. Type(s) of reasonable accommodation requested:
    
    
3. Request for reasonable accommodation denied because: (may check more than one box)
   • Accommodation Ineffective
   • Accommodation Would Cause Undue Hardship
   • Medical Documentation Inadequate
   • Accommodation Would Require Removal of an Essential Function
   • Accommodation Would Require Lowering of Performance or Production Standard
   • Other (Please identify) ______________________
4. Detailed Reason(s) for the denial of reasonable accommodation (Must be specific, e.g., why accommodation is ineffective or causes undue hardship):
    
    
    
    
    
    
    
5. If the individual proposed one type of reasonable accommodation which is being denied, but rejected an offer of a different type of reasonable accommodation, explain both the reasons for denial of the requested accommodation and why you believe the chosen accommodation would be effective.
    
    
    
    
    
    
    
6. If an individual wishes to request reconsideration of this decision, s/he may take the following steps:
   • First, ask the decision maker to reconsider his/her denial. Additionalinformation may be presented to support this request.
   • If the decision maker does not reverse the denial:
     • and the decision maker was the individual's supervisor, the individual can ask the Office Director to do so.
     • and the decision maker was the Office Director, the individual can ask the Disability Program Manager to do so.
     • and the decision maker was the Disability Program Manager, the individual can ask the official designated by the Director of the Office of Equal Opportunity to do so.
7. If an individual wishes to file an EEO complaint, or pursue MSPB and union grievance procedures, s/he must take the following steps:
   • For an EEO complaint pursuant to 29 C.F.R. § 1614, contact an EEO counselor in the Office of Equal Opportunity within 45 days from the date of this notice of denial of reasonable accommodation; or
   • For a collective bargaining claim, file a written grievance in accordance with the provisions of the Collective Bargaining Agreement; or
   • Initiate an appeal to the Merit Systems Protection Board within 30 days of an appealable adverse action as defined in 5 C.F.R. § 1201.3.