Blank 13661 Template

The Form 13661 is a document used to request reasonable accommodations in the workplace for individuals with disabilities. This form allows applicants, employees, or IRS officials to clearly outline their needs and provide necessary medical documentation to support their requests. Understanding how to properly complete this form is essential for ensuring that your accommodation needs are met effectively.

Ready to take the next step? Fill out the form by clicking the button below.

Article Structure

The 13661 form plays a crucial role in the process of requesting reasonable accommodations for employees and applicants with disabilities. This form is divided into several parts, each serving a specific purpose. Part I is where the individual seeking accommodation outlines their request, providing details about their medical condition and how it affects their job functions. Part II is designed for the Deciding Official to document their assessment of the request, including whether the accommodation will enable the individual to perform essential job functions. Medical professionals complete Parts III-A and III-B, providing necessary documentation that supports the accommodation request and outlines any limitations the individual may face. If a request for accommodation is denied, Part IV is used to formally document the reasons for the denial. Importantly, the form includes a privacy statement that highlights the protections around personal medical information, ensuring compliance with laws like the Rehabilitation Act and the Genetic Information Nondiscrimination Act (GINA). Understanding the components of the 13661 form is essential for both employees and employers to navigate the reasonable accommodation process effectively.

Form Sample

Form

13661

(Rev. 10-2020)

Catalog Number 39619X publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Instructions for Form 13661, Reasonable Accommodation Request

This form is intended to assist persons involved in the reasonable accommodation process and to

memorialize important information. Completion of the form, including medical documentation if the

condition is not obvious or history of, is strongly encouraged for Agency Reasonable Accommodation

Services (RAS) review and record keeping purposes.

Part I – Written Reasonable Accommodation Request

To be completed by applicant for employment, employee, representative, or by an IRS

official when necessary to document a reasonable accommodation request. Submitting

any medical or other supporting documentation with Part I will help expedite the

processing of the request for accommodation.

Part II-A – Deciding Official Documentation

To be completed by Supervisor or Deciding Official addressing management's decision.

Management makes the final decision on a request for accommodation.

Part II-B –

Deciding Official Documentation

To be completed by Supervisor or Deciding Official addressing management's decision.

Management makes the final decision on a request for accommodation. A temporary

request, condition, or accommodation should be documented on Part I and Part II with re-

evaluation or ending date.

Part III-A – Medical Documentation

To be completed by Health Care Practitioner, Social Worker, or Rehabilitation Counselor.

Part III-B – Medical Documentation (Limitations Worksheet)

To be completed by Health Care Practitioner, Social Worker, or Rehabilitation Counselor.

Note: Medical documentation is generally not required where the disability is obvious or

known to the Agency and the nexus between the disability and the requested

accommodation is apparent.

Part IV – Denial of Reasonable Accommodation Request

To be completed by Deciding Official to document the denial of reasonable

accommodation.

Authorization of Representation – To be completed by representative and/or employee for

authorized representation for request.

Collection of the requested information is authorized by Section 501 of the Rehabilitation Act, 29 U.S.C. § 791.The information you

furnish will be used for the purpose of facilitating your request. Additionally, the information may be used to disclose information to:

appropriate Federal, state or local agencies when relevant to civil, criminal or regulatory investigations or prosecutions when necessary

to adjudicate a claim for benefits; a Federal agency in connection with a decision in hiring, retention or the granting of a security

clearance. It may also be used in an administrative or judicial proceeding affecting an employee's personnel rights and in any criminal

prosecutions for willfully making false or fraudulent statements in violation of U.S.C. § 1001. Additional uses may include disclosure to

the Department of Justice for the purpose of litigating any civil, administrative, or judicial proceeding where the United States, the IRS,

or its employees (in their official capacities or where the government has decided to represent them) are parties. It may also be used in

response to subpoena from a third party provided that (1) IRS is a party in interest, (2) the records are relevant and necessary to the

litigation, and (3) not otherwise privileged. This information may be provided to professional associations, such as state bar disciplinary

authorities, for use in connection with their administration of standards of conduct. Further, it may be disclosed to contractors when

necessary to perform work associated with reasonable accommodation and to those Federal agencies that oversee property and

procurement matters. Furnishing the requested information is required to establish that you have a covered disability, the functional

limitations of your disability, and the need for reasonable accommodation. Failure to fully complete the form or refusal to provide the

requested documentation may lead to a breakdown in the reasonable accommodation process and could result in a determination that

you are not entitled to reasonable accommodation.

Privacy Act Statement

Form

13661

(Rev. 10-2020)

Catalog Number 39619X publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Nondisclosure of GINA Protected Information

The Genetic Information and Nondiscrimination Act of 2008 (GINA) prohibits employers and other

entities covered by GINA Title II from requesting, requiring, or purchasing genetic information of

employees or their family members, except as specifically allowed by this law. GINA has specific

exceptions for requests under the Family and Medical Leave Act and the Rehabilitation Act, as

explained below. To comply with GINA, we are asking that you not provide any genetic information

when responding to this request for medical information, unless the information is allowable as

explained below.

“Genetic information”, as defined by GINA, includes information concerning the manifestation of

disease/disorder in family members (“family medical history”), information about 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. Document 12986 - Nondisclosure of GINA Protected Information

(Provided for your information).

Family and Medical Leave Act (FMLA)

The general prohibition against requesting or requiring genetic information does not apply where

an employer requests medical information of an employee who invokes the FMLA to attend to

the employee's own serious health condition or where an employee complies with the employer's

return to work certification requirements. See 29 CFR 1635.8(b)(1)(i)(D)(2). An employer does not

violate GINA by asking an employee seeking FMLA leave to care for a seriously ill family member to

provide family medical history to comply with the certification provisions of the FMLA. See 29 CFR

1635.8(b)(3).

Further, GINA permits disclosure of relevant genetic information consistent with the requirements of

the FMLA to persons with a need to know the information because of responsibilities relating to the

handling of FMLA requests. See 29 CFR 1635.9(b)(5).

Rehabilitation Act

The general prohibition against requesting or requiring genetic information does not apply where an

employer requests documentation to support a request for reasonable accommodation as long as the

request for documentation is lawful. Such a request is lawful only where the disability and/or the need

for accommodation is not obvious; the documentation required contains no more information than

what is sufficient to establish that an individual has a disability and needs reasonable accommodation;

and the documentation relates only to the impairment that the individual claims to be a disability that

requires reasonable accommodation. See 29 CFR 1635.8(b)(1)(i)(D)(1); see also 29 CFR 1635.8(b)

(1)(i)(B).

Reasonable Accommodation Request

Form

13661

(Rev. 10-2020)

Catalog Number 39619X publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Part I

Part I. Written Reasonable Accommodation Request

To be completed by applicant, employee, or IRS official

1. Applicant/Employee information

Last name First name

2. Occupational

SEID Series Grade

3. Operating Division/Function

4. Contact information

Office telephone number FAX number Tour of Duty/Shift (work hours)

Post of Duty (POD) City State ZIP code

E-mail address Preferred method/time to contact (cell phone or email, hours)

Cubicle, floor, or building code

5. Mailing address (where you receive official correspondence)

Address 1

(work)

Address 2

(home)

Room # Mail Stop City State ZIP code

6. Manager's contact information

Manager's name Telephone number E-mail address

ZIP codeStatePost of Duty (POD) City

SEID

7. Medical condition

(Describe your medical condition requiring accommodation.)

8. Job functions affected

(Describe how your medical condition limits your ability to perform your current duties, participate in the application process,

or access a benefit of employment. Copy of position description or clarify essential job functions impacted.)

9. Accommodation requested

(Based on your disability or medical condition and job functions affected, what accommodations would help you to

perform effectively.)

10. List alternative accommodation options to consider

I affirm that all statements made above are true to the best of my knowledge and belief.

Signature of Applicant/Employee Date signed

Authorization of Representation Name / Contact Information (attach release form to package)

eFAX 855-679-8653 or * RA Form 13661

Page

Reasonable Accommodation Request

Form

13661

(Rev. 10-2020)

Catalog Number 39619X publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Part II-A

Part II-A. Supervisor/Deciding Official Documentation

To be completed by Supervisor/Deciding Official

1. Name of Applicant/Employee RA case number

2. Supervisor/Deciding Official

Last name First name Title SEID

ZIP codeStatePost of Duty

(POD)

City

Telephone number

(Including Area Code)

E-mail address

3. Is the employee's/applicant's condition obvious or otherwise known to management

Yes No

4. What duties or functions of the job are limited by the applicant/employee's medical condition.

(Refer to the Position Description, Critical

Job Elements (CJE), applicant requirements, or other relevant documentation).

5. Does this limitation affect an essential function of the job or participation in the application process

(See RAC if

essential job function worksheet is needed).

Explain answer

Yes No

6. Will the requested accommodation allow the applicant/employee to successfully perform the

essential job functions or participate in the application process. Explain answer

Yes No Not sure

7. Describe any interim accommodation efforts, alternative accommodation recommendations or previously approved accommodations

8. Further medical information/review: Does management need additional medical information

Yes No

9. Potential review through Federal Occupational Health (FOH)

Yes No

If either additional medical information or review by FOH is necessary. Explain the need

(Additional medical information should not

be sought where the condition is obvious or known and the connection to the requested accommodation is apparent)

I affirm all statements made above are true to the best of my knowledge and belief.

Signature of Supervisor/Deciding Official Date signed

eFAX 855-679-8653 or * RA Form 13661

Reasonable Accommodation Request

Department of the Treasury - Internal Revenue Servicepublish.no.irs.govCatalog Number 39619X

Form

13661

(Rev. 10-2020)

Part II-B

Part II-B. Action by Deciding Official

To Be Completed After Review of Accommodation Request

Request approved Alternative accommodation approved Accommodation denied

If an alternative accommodation approved, describe accommodation approved

If the condition and/or accommodation is temporary, document specifics with date to re-evaluate. Review date

Signature of Deciding Official Date signed

Deciding Official

Last name

First name Title SEID

Telephone number

(Including Area Code)

E-mail address

Post of Duty

(POD)

City State ZIP code

eFAX 855-679-8653 or * RA Form 13661

Reasonable Accommodation Request

Department of the Treasury - Internal Revenue Servicepublish.no.irs.govCatalog Number 39619X

Form

13661

(Rev. 10-2020)

Part III-A Name of Health Care Practitioner, Social Worker, Rehabilitation Counselor Best method and time to contact Signature

Part III-A. 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

modification made to a job and/or the work environment that enables a qualified employee/applicant with a disability to successfully

perform the essential duties or functions of the position. We request that you provide medical information which reflects:

• the individual has one or more physical or mental impairment that substantially limit(s) one or more of his/her major life activities

(e.g., walking, speaking, breathing, hearing, seeing, thinking, sitting, standing, reaching, interacting with others, learning,

performing manual tasks, caring for oneself, concentrating, lifting, working, sleeping),

• a relationship or nexus between the medical condition(s) and the recommended accommodation(s).

Medical Documentation; provide a copy of employee position or job description

1. Have you made a diagnosis that relates to this reasonable accommodation request? State the diagnosis

2. Describe what limitations result from this condition, address any workplace safety concerns or impact to perform essential job duties

that may result from the condition.

(Complete Part III-B)

3. What is the anticipated duration of this medical condition

4. Recommended options or alternatives for accommodation efforts

Certification

Name of Health Care Practitioner, Social Worker, Rehabilitation Counselor Telephone number Best method and time to contact

I understand an IRS medical consultant may contact me for additional information.

Signature Date signed

eFAX 855-679-8653 or

* RA Form 13661

Reasonable Accommodation Request

Form

13661

(Rev. 10-2020)

Catalog Number 39619X publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Part III-B

Part III-B. Medical Documentation

To be completed by a Health Care Practitioner, Social Worker, or Rehabilitation Counselor

Name of Applicant/Employee

Instructions

1. The following table indicates the major life activity that is affected by the applicant/employee's medical condition. Major life

activities are those basic activities that the average person in the general population can perform with little or no difficulty.

2. Indicate only the major activity affected by the applicant / employee's medical condition by circling or checking the appropriate

block. Indicate the specific limitation of the applicant / employee resulting from their condition. Quantify their limitation in order for

the agency to determine appropriate workplace accommodations (1-2 hours, 100 feet, 75% of day, or other notation).

Activity Extent of Limitation Detailed Explanation/Recommendation

Sensory

Seeing/Vision

Hearing

Limited to:

Breathing/Respiratory

Limited to:

Speaking

Limited to:

Basic Mobility

Walking

Climbing stairs

Sitting

Standing

Limited to:

Hours per day

Distance

% of day

Secondary Mobility

Squatting/kneeling

Twisting (neck/waist)

Bending/stooping

Reaching above shoulder

Limited to:

Hours per day

Physical Exertion

Pushing/pulling

Lifting/Carrying

Limited to:

Number of pounds

Fine Motor Skills

Keyboard use

Repetitive use of hands

Grasping

Fine finger motions

Limited to:

Hours per day

Cognitive

Thinking

Learning

Comprehending

Concentrating

Limited to:

Caring for self

Self-medication/checks

Dressing

Limited to:

Mental/emotional

Limited to:

Sleeping

Limited to:

Other/Bodily Functions

Limited to:

Certification

Name of Health Care Practitioner, Social Worker, Rehabilitation Counselor Signature Date signed

eFAX 855-679-8653 or

* RA Form 13661

Reasonable Accommodation Request

Form

13661

(Rev. 10-2020)

Catalog Number 39619X publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Part IV

Part IV. Denial of Reasonable Accommodation Request

To be completed by Deciding Official

Name of Applicant/Employee RA case number

Accommodation requested Accommodation offered to Applicant/Employee

1. Reason for denial

(check all that apply)

Accommodation Ineffective/Inappropriate

Accommodation Would Cause Undue Hardship

Employee did not accept an alternative accommodation offered

Medical Documentation Inadequate

Accommodation Would Require Removal of Essential Function

Accommodation Would Require Lowering of Performance or Production Standard

Other (Identify)

2. Detailed reason(s) for the denial of reasonable accommodation

(e.g., why accommodation is ineffective or causes undue hardship)

3. If the individual did not accept an alternative accommodation, explain how the alternative accommodation addresses the limitation,

and why you believe the chosen accommodation would be effective

4. Appeal Process:

• Refer to IRM 1.20.2.

• A request to the Deciding Official for reconsideration based on new medical documentation or other previously unavailable

information may be made within 15 business days of receipt of this denial.

• An appeal to the Business Unit Chief/Commissioner may be initiated within 15 business days of the denial of accommodation or

within 15 business days of a denial of a request for reconsideration by the Deciding Official, unless an alternative effective

accommodation has been offered.

• To initiate an EEO complaint contact an EEO counselor within the IRS within 45 calendar days of an allegedly discriminatory

action/event.

• Bargaining Unit employees may file a grievance in accordance with the terms of the collective bargaining agreement.

• An appeal to the Merit Systems Protection Board may be filed within 30 calendar days of an adverse action as defined in 5 C.F.R.

1201.3.

Signature of Deciding Official

(If denied)

Date signed

eFAX 855-679-8653 or * RA Form 13661

⇩ PDF

Document Specifications

Fact Name	Details
Form Purpose	The 13661 form is used to request reasonable accommodations for employees or applicants with disabilities.
Parts of the Form	The form consists of four main parts: the accommodation request, documentation by the deciding official, medical documentation, and denial documentation.
Privacy Act Statement	Information collected is authorized by Section 501 of the Rehabilitation Act and is used to facilitate accommodation requests and may be disclosed under certain conditions.
GINA Compliance	The form adheres to the Genetic Information Nondiscrimination Act (GINA) by prohibiting the collection of genetic information unless specifically allowed.
Medical Documentation	Health care practitioners must complete sections that address the applicant's medical condition and its impact on job performance.
State-Specific Laws	State laws may vary; for instance, California's Fair Employment and Housing Act (FEHA) provides additional protections for individuals with disabilities.
Submission Process	The completed form can be submitted via fax or to the assigned Reasonable Accommodation Coordinator for review.

Steps to Filling Out 13661

Filling out Form 13661 can seem daunting, but breaking it down into manageable steps makes the process smoother. Once you have the form ready, you’ll be able to submit your request for reasonable accommodation. Follow these steps carefully to ensure that you provide all necessary information.

Gather your personal information. You will need your last name, first name, occupational SEID, series, and grade.
Provide your contact information. Fill in your office phone number, fax number, email address, and preferred method for contact.
Complete your mailing address. Make sure to include your home address, room number, mail stop, city, state, and ZIP code.
Include your manager's contact information. Write down your manager's name, phone number, and email address.
Describe your medical condition. Clearly explain the medical condition that requires accommodation.
Detail job functions affected. Describe how your medical condition limits your ability to perform your current duties.
Specify the accommodation requested. List the accommodations that would help you perform effectively.
Add any additional comments. Use this space to provide further information if needed.
Sign and date the form. Ensure that you affirm the accuracy of your statements by signing and dating the form.
Submit Part I. Return it via fax to 855-679-8653 or to the assigned Reasonable Accommodation Coordinator.

Once you submit the form, the appropriate officials will review your request. They may need to gather additional information or documentation before making a decision. Stay tuned for updates on your request, and be prepared to provide any further details if asked.

More About 13661

What is Form 13661 used for?

Form 13661 is designed to facilitate requests for reasonable accommodations within the workplace. It serves as a formal document for applicants or employees to detail their needs related to a medical condition that may impact their job performance. The form collects information necessary for decision-makers to evaluate the request and determine appropriate accommodations.

Who is eligible to submit Form 13661?

Any applicant for employment or current employee who has a medical condition that limits their ability to perform essential job functions can submit Form 13661. This includes individuals who may require adjustments to their work environment or job duties to effectively carry out their responsibilities.

What information is required in Part I of Form 13661?

Part I requires the applicant or employee to provide personal information, including their name, job title, and contact details. Additionally, they must describe their medical condition, explain how it affects their job functions, and specify the accommodations they are requesting. If more space is needed, an attachment may be included.

What role does the Deciding Official play in the process?

The Deciding Official is responsible for reviewing the accommodation request and making a determination based on the information provided. This individual must assess how the medical condition affects the employee's job functions and whether the requested accommodations will enable the employee to perform essential duties. Their findings are documented in Part II of the form.

Is medical documentation required for the request?

Yes, medical documentation is often required to support the request for reasonable accommodation. This documentation, which is typically completed by a healthcare practitioner, social worker, or rehabilitation counselor, must confirm the medical condition and its impact on major life activities. It helps establish the need for the requested accommodations.

What happens if my request for accommodation is denied?

If a request for accommodation is denied, the Deciding Official will complete Part IV of the form to document the reasons for denial. This section is crucial as it provides the applicant with clarity on the decision. It is advisable for the applicant to seek further clarification or consider appealing the decision if they believe it was unjustified.

How is my privacy protected when submitting Form 13661?

The information provided on Form 13661 is protected under the Privacy Act. The form explicitly states that the collected information is used solely for the purpose of evaluating the accommodation request. Additionally, it outlines circumstances under which information may be disclosed, ensuring that personal details are kept confidential and only shared with relevant parties involved in the accommodation process.

Can I submit additional information if there is not enough space on the form?

Absolutely. If you find that there is not enough space to adequately provide the necessary information on Form 13661, you are encouraged to attach additional sheets. This ensures that all relevant details are included and can be considered during the review process.

What should I do if I have questions about completing the form?

If you have questions about how to complete Form 13661 or need assistance, it is advisable to reach out to your HR department or the designated Reasonable Accommodation Coordinator. They can provide guidance and help clarify any uncertainties you may have regarding the process.

What is the significance of the Genetic Information Nondisclosure Act (GINA) in relation to this form?

GINA prohibits employers from requesting or requiring genetic information from employees, which includes family medical history. When completing Form 13661, it is important to avoid providing any genetic information unless it is specifically allowed under exceptions related to the Family and Medical Leave Act or the Rehabilitation Act. This ensures compliance with GINA while still addressing the need for reasonable accommodations.

Common mistakes

Incomplete Personal Information: Failing to provide all necessary personal details, such as last name, first name, and contact information, can delay the processing of the request. Ensure that all fields are filled out accurately.
Insufficient Medical Documentation: Not including adequate medical documentation can lead to a denial of the accommodation request. It is essential to attach detailed medical information that supports the need for accommodation.
Failure to Specify Accommodation Needs: Vague descriptions of the requested accommodations can create confusion. Clearly outline what specific accommodations are needed to perform job duties effectively.
Ignoring Signature Requirement: Omitting the signature and date can render the form invalid. Always sign and date the form before submission to ensure it is processed.
Not Providing Alternative Contact Information: Failing to include alternative contact methods can hinder communication. Provide multiple ways for the deciding official to reach you, such as email and phone number.
Neglecting to Follow Up: After submitting the form, not following up can lead to uncertainty about the status of the request. It is advisable to check in with the appropriate office after a reasonable amount of time.
Overlooking Confidentiality Requirements: Providing genetic information or other sensitive data that is not required can violate privacy laws. Stick to the information specifically requested in the form.

Documents used along the form

The 13661 form, which serves as a Reasonable Accommodation Request Document, is often accompanied by various other forms and documents that facilitate the accommodation process. Each of these documents plays a critical role in ensuring that requests are properly evaluated and addressed. Below is a list of six key forms and documents that are commonly used alongside the 13661 form.

Nondisclosure of GINA Protected Information: This document outlines the requirements set forth by the Genetic Information Nondiscrimination Act (GINA). It emphasizes the prohibition against employers requesting genetic information from employees and clarifies the exceptions under which such information may be disclosed.
Family and Medical Leave Act (FMLA) Documentation: This form is utilized to support requests for leave related to serious health conditions. It provides guidelines for employers on how to handle medical information while ensuring compliance with both FMLA and GINA regulations.
Medical Documentation (Part III-A): This section of the 13661 form must be completed by a healthcare practitioner, social worker, or rehabilitation counselor. It includes necessary medical information that verifies the individual’s disability and the need for accommodation.
Limitations Worksheet (Part III-B): Also completed by a healthcare professional, this worksheet focuses specifically on the limitations imposed by the individual’s medical condition. It provides further detail on how these limitations affect the person's ability to perform essential job functions.
Deciding Official Documentation (Part II-A): This document is filled out by the Deciding Official and serves to track the decision-making process regarding the accommodation request. It records the essential functions affected by the medical condition and any alternative accommodations that may be suggested.
Denial of Reasonable Accommodation Request (Part IV): Should a request for accommodation be denied, this section is completed by the Deciding Official. It documents the reasons for the denial and ensures that the applicant is informed of the decision.

Utilizing these forms and documents in conjunction with the 13661 form enhances the clarity and efficiency of the reasonable accommodation process. Each document contributes to a thorough understanding of the request, ensuring that both the employee's needs and the employer's obligations are met effectively.

Similar forms

The Form 13661 is similar to the Family and Medical Leave Act (FMLA) documentation. Both forms require individuals to provide specific medical information to support their requests. In the case of FMLA, employees must submit medical certification to justify their need for leave due to their own serious health condition or to care for a family member. Just like Form 13661, the FMLA documentation aims to ensure that the employee's medical needs are met while balancing the employer's requirements for verification.

Another document that parallels Form 13661 is the Americans with Disabilities Act (ADA) request form. This form facilitates the process for individuals seeking accommodations due to a disability. Both documents collect information about the individual's medical condition and how it affects their ability to perform essential job functions. The ADA request form, like Form 13661, emphasizes the need for clear documentation to support the request for accommodations in the workplace.

The medical certification form for workers' compensation claims also shares similarities with Form 13661. Both require medical documentation that outlines the nature of an individual's condition and its impact on their ability to work. In workers' compensation cases, the focus is on establishing a direct link between the medical condition and the workplace injury. Similarly, Form 13661 seeks to establish the necessity for reasonable accommodations based on the individual's medical needs.

The Equal Employment Opportunity Commission (EEOC) intake questionnaire is another document akin to Form 13661. Both are used to gather information about an individual's circumstances regarding employment and any perceived discrimination. The EEOC questionnaire helps determine if there is a basis for an employment discrimination claim, while Form 13661 focuses on the need for reasonable accommodations due to a disability.

Additionally, the Disability Verification Form used by various employers is similar to Form 13661. This form collects information from healthcare providers to verify an employee's disability status. Both documents require detailed medical information to substantiate the claims made by the individual. The goal is to ensure that appropriate accommodations are provided based on the verified disability.

The Request for Reasonable Accommodation form under the Rehabilitation Act also bears resemblance to Form 13661. Both forms are used by individuals seeking accommodations in the workplace due to disabilities. They require detailed descriptions of the individual's medical condition and the specific accommodations requested. The emphasis in both forms is on ensuring that the individual's rights are protected while providing necessary support in the work environment.

The Social Security Administration's disability application form is another document that parallels Form 13661. This application requires detailed medical information to assess an individual's eligibility for disability benefits. Similar to Form 13661, the SSA form aims to establish the impact of a medical condition on an individual's ability to work and perform daily activities. Both forms are crucial for ensuring that individuals receive the support they need based on their medical circumstances.

Finally, the medical release form used in various employment contexts is similar to Form 13661. This document allows employers to obtain necessary medical information from healthcare providers to evaluate an employee's request for accommodations. Both forms prioritize the protection of the individual's privacy while ensuring that relevant medical information is shared to facilitate the accommodation process.

Dos and Don'ts

When filling out Form 13661, it is important to approach the process with care. Here are some guidelines to help ensure that the form is completed correctly.

Do provide accurate and complete information. Ensure that all sections of the form are filled out thoroughly. Missing or incorrect information can delay the accommodation process.
Do attach additional information if needed. If there isn't enough space on the form to describe your situation fully, feel free to include an attachment with the necessary details.
Don't include genetic information. Be mindful of the Genetic Information Nondiscrimination Act (GINA) and avoid providing any genetic information that is not required for your request.
Don't hesitate to seek assistance. If you're unsure about any part of the form or the process, reach out to your manager or the Reasonable Accommodation Coordinator for guidance.

Following these do's and don'ts can make the process smoother and help ensure that your request for reasonable accommodation is handled effectively.

Misconceptions

Misconception 1: The 13661 form is only for employees.

This form can be used by applicants for employment as well as current employees. It is designed to document reasonable accommodation requests regardless of employment status.

Misconception 2: Medical documentation is not necessary.

Medical documentation is essential for establishing the need for reasonable accommodation. The form requires input from a health care practitioner, social worker, or rehabilitation counselor to support the request.

Misconception 3: The information provided on the form is completely confidential.

While the form collects sensitive information, it may be disclosed to various federal, state, or local agencies under specific circumstances, such as investigations or legal proceedings.

Misconception 4: Submitting the form guarantees approval of the accommodation request.

Filling out the form does not ensure that the request will be approved. The decision will depend on the information provided and the nature of the accommodation requested.

Misconception 5: You cannot submit additional information if the form lacks space.

If there is insufficient space on the form, you can attach additional information as needed. It is encouraged to provide all relevant details to support your request.

Key takeaways

Complete All Parts: Ensure that every section of the 13661 form is filled out accurately. Missing information can delay the accommodation process.
Attach Additional Information: If there isn’t enough space in any section, include an attachment with the necessary details. This helps provide a complete picture of your request.
Understand Privacy Implications: Be aware that the information you provide may be shared with various agencies or professionals involved in the accommodation process. Your privacy is important, but full disclosure is necessary for proper evaluation.
Medical Documentation: If required, ensure that any medical documentation is provided by a qualified professional. This documentation should clearly outline your condition and how it impacts your job functions.