➾

Fill in Your 13661 Template

The 13661 form is a document used to request reasonable accommodations for individuals with disabilities in the workplace. It serves as a means for employees, applicants, or IRS officials to formally document their accommodation needs. The form includes sections for medical documentation, decision-making, and potential denial of requests, ensuring a structured process for addressing accommodation requests.

Table of Contents

The 13661 form is an essential tool designed to facilitate the process of requesting reasonable accommodations in the workplace. It is divided into several parts, each serving a specific purpose to ensure that requests are documented and handled appropriately. Part I is where applicants, employees, or IRS officials provide their written request for accommodation, detailing their medical condition and how it affects their job functions. Part II includes documentation from the Deciding Official, who assesses the request and tracks information relevant to the accommodation process. Medical professionals, such as health care practitioners or social workers, complete Parts III-A and III-B, which focus on providing necessary medical documentation to support the request. Additionally, the form includes a section for the Deciding Official to document any denial of the request in Part IV. Privacy is a priority, and the form outlines how the information collected will be used and protected under the Privacy Act. Understanding the components of the 13661 form is crucial for both employees and employers to navigate the reasonable accommodation process effectively and compassionately.

Sample - 13661 Form

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.

Privacy Act Statement

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.

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).

Form 13661 (Rev. 10-2020)

Catalog Number 39619X

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

Reasonable Accommodation Request

Part I. Written Reasonable Accommodation Request

To be completed by applicant, employee, or IRS official

1. Applicant/Employee information		2. Occupational

Last name	First name	SEID	Series	Grade

3. Operating Division/Function

4. Contact information

Office telephone number	FAX number	Cubicle, floor, or building code	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)

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	SEID	Telephone number	E-mail address

Post of Duty (POD) City

State

ZIP code

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

Form 13661 (Rev. 10-2020)

Catalog Number 39619X

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

Part I

Page 4

Reasonable Accommodation Request

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

Post of Duty (POD) City

First name	Title		SEID

	State	ZIP code

Telephone number (Including Area Code)

E-mail address

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

Yes

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

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

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

Form 13661 (Rev. 10-2020)	Catalog Number 39619X	publish.no.irs.gov	Department of the Treasury - Internal Revenue Service

Part II-A

Reasonable Accommodation Request

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

Form 13661 (Rev. 10-2020)

Catalog Number 39619X

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

Part II-B

Reasonable Accommodation Request

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

Form 13661 (Rev. 10-2020)	Catalog Number 39619X	publish.no.irs.gov	Department of the Treasury - Internal Revenue Service

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

Reasonable Accommodation Request

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		Limited to:
Sensory		Limited to:
Seeing/Vision
Hearing

Breathing/Respiratory		Limited to:
Breathing/Respiratory		Limited to:

Speaking		Limited to:
Speaking		Limited to:

Basic Mobility		Limited to:
Basic Mobility		Limited to:
Walking			Hours per day
Climbing stairs			Distance
Climbing stairs
Sitting
Sitting			% of day
Standing			% of day

Secondary Mobility		Limited to:
Secondary Mobility		Limited to:
Squatting/kneeling
Twisting (neck/waist)			Hours per day
Bending/stooping
Reaching above shoulder

Physical Exertion		Limited to:
Physical Exertion		Limited to:
Pushing/pulling			Number of pounds
Lifting/Carrying
Lifting/Carrying

Fine Motor Skills		Limited to:
Fine Motor Skills		Limited to:
Keyboard use
Repetitive use of hands			Hours per day
Grasping
Fine finger motions

Cognitive		Limited to:
Cognitive		Limited to:
Thinking
Learning
Comprehending
Concentrating

Caring for self		Limited to:
Caring for self		Limited to:
Self-medication/checks
Dressing

Mental/emotional		Limited to:
Mental/emotional		Limited to:

Sleeping		Limited to:
Sleeping		Limited to:

Other/Bodily Functions		Limited to:

Certification

Name of Health Care Practitioner, Social Worker, Rehabilitation Counselor

Signature

eFAX 855-679-8653 or * RA Form 13661

Date signed

Form 13661 (Rev. 10-2020)

Catalog Number 39619X

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

Part III-B

Reasonable Accommodation Request

Part IV. Denial of Reasonable Accommodation Request

To be completed by Deciding Official

Name of Applicant/Employee	RA case number

Accommodation requested

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 offered to Applicant/Employee

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

Form 13661 (Rev. 10-2020)

Catalog Number 39619X

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

Part IV

↓ 13661 PDF

File Specs

Fact Name	Details
Purpose of Form	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: a request by the individual, documentation by a Deciding Official, medical documentation, and a section for denial of accommodation requests.
Medical Documentation	Health Care Practitioners, Social Workers, or Rehabilitation Counselors must complete Parts III-A and III-B to provide medical information related to the accommodation request.
Privacy Considerations	The form includes a Privacy Act Statement, outlining how collected information may be used, including compliance with various federal laws.
GINA Compliance	Under the Genetic Information Nondiscrimination Act (GINA), the form prohibits the collection of genetic information unless specifically allowed under certain conditions.
Rehabilitation Act Reference	The form is governed by Section 501 of the Rehabilitation Act, which mandates reasonable accommodation for individuals with disabilities.
Submission Process	Completed forms should be returned to the designated Reasonable Accommodation Coordinator or faxed to the specified number.
Consequences of Incomplete Submission	Failure to provide complete information may hinder the accommodation process and could result in a denial of the request.

13661 - Usage Guidelines

Filling out Form 13661 is a straightforward process. The form is divided into several parts that need to be completed by different individuals involved in the reasonable accommodation request. Make sure to provide accurate and complete information to facilitate the process.

Gather Necessary Information: Before starting, collect all relevant information, including personal details, medical conditions, and accommodation requests.
Complete Part I: Fill in your name, contact information, job details, and describe your medical condition and how it affects your job functions. Be clear about the accommodations you are requesting.
Sign and Date Part I: At the end of Part I, sign and date the form to affirm that the information provided is true to the best of your knowledge.
Submit Part I: Send Part I to the designated fax number or to the assigned Reasonable Accommodation Coordinator.
Deciding Official Completes Part II: The Deciding Official will fill out Part II, which includes details about the applicant's medical condition and the impact on job functions.
Review and Decision: The Deciding Official will determine if the requested accommodation can be approved or if additional information is needed.
Complete Medical Documentation (Part III): If required, a Health Care Practitioner, Social Worker, or Rehabilitation Counselor will need to complete Part III-A and Part III-B to provide medical documentation regarding the condition.
Return Medical Documentation: Ensure that Part III is returned to the assigned Reasonable Accommodation Coordinator.
Receive Final Decision: After all parts are completed and submitted, await the final decision regarding your accommodation request.

Your Questions, Answered

What is the purpose of Form 13661?

Form 13661 is designed to facilitate the process of requesting reasonable accommodations for individuals with disabilities. It allows applicants, employees, or IRS officials to document their requests for accommodations that enable them to perform essential job functions. The form collects necessary information about the individual's medical condition, how it affects their job performance, and the specific accommodations being requested.

Who is required to complete the different parts of Form 13661?

The form is divided into several parts that need to be completed by different individuals. Part I must be filled out by the applicant or employee requesting the accommodation. Part II is for the Deciding Official, who assesses the request and its implications for job performance. Parts III-A and III-B are to be completed by a Health Care Practitioner, Social Worker, or Rehabilitation Counselor, providing medical documentation to support the accommodation request. If a request is denied, Part IV is completed by the Deciding Official to document the reasons for denial.

What kind of information is required in Part I of the form?

In Part I, the applicant or employee must provide personal information, including their name, job title, and contact details. They also need to describe their medical condition and how it limits their ability to perform job functions. Furthermore, the individual must specify the accommodations they believe would assist them in effectively carrying out their duties. If there is not enough space on the form, additional information can be attached.

What happens if the reasonable accommodation request is denied?

If a request for reasonable accommodation is denied, the Deciding Official must complete Part IV of the form. This section documents the reasons for denial and ensures that the applicant is informed about the decision. It is essential for the process, as it provides transparency and allows the applicant to understand the basis for the decision.

How does the Privacy Act affect the information provided on Form 13661?

The Privacy Act governs the collection and use of personal information provided on Form 13661. The information collected is used solely for the purpose of processing the reasonable accommodation request. It may be disclosed to relevant federal, state, or local agencies for investigations or legal proceedings. Individuals are encouraged to provide accurate information, as failure to do so may hinder the accommodation process.

Common mistakes

Failing to provide complete contact information. It’s essential to include all relevant contact details, such as phone numbers and email addresses. Missing this information can delay the processing of the request.
Not specifying the medical condition clearly. When describing the medical condition that necessitates accommodation, clarity is key. Vague descriptions may lead to misunderstandings and could hinder the approval process.
Overlooking the need for manager's contact information. Including your manager’s details helps streamline communication. If this information is missing, it can create obstacles in the accommodation review process.
Neglecting to explain how the medical condition affects job functions. It is important to detail how your condition limits your ability to perform specific job duties. This information is crucial for the decision-making process.
Not signing and dating the form. A signature and date are necessary to validate the request. Without them, the form may be considered incomplete and could lead to delays or denials.

Documents used along the form

The 13661 form is a crucial document for individuals seeking reasonable accommodation in the workplace due to a disability. It serves as a formal request and outlines the necessary medical documentation and decision-making processes involved. Alongside the 13661 form, several other forms and documents are often used to facilitate the accommodation process. Each of these documents plays a distinct role in ensuring that the request is handled appropriately and in compliance with relevant laws.

Form 12986 – Nondisclosure of GINA Protected Information: This document informs individuals about the Genetic Information Nondiscrimination Act (GINA) and outlines the restrictions on collecting genetic information during the accommodation process. It emphasizes the importance of not disclosing such information unless specifically permitted.
Family and Medical Leave Act (FMLA) Certification: This form is used when an employee requests leave under the FMLA due to a serious health condition. It requires medical documentation to support the leave request and may overlap with reasonable accommodation requests.
Medical Documentation (Part III-A): This section of the 13661 form must be completed by a healthcare practitioner. It provides essential information regarding the applicant's medical condition, the impact on major life activities, and the relationship between the condition and the requested accommodations.
Limitations Worksheet (Part III-B): Also completed by a healthcare practitioner, this worksheet details the specific limitations caused by the medical condition. It aids in clarifying the extent of the individual's disability and the necessity for accommodation.
Deciding Official Documentation (Part II-A): This part of the 13661 form is filled out by the Deciding Official. It documents the official's assessment of the accommodation request, including the job functions affected and any alternative recommendations for accommodation.
Denial of Reasonable Accommodation Request (Part IV): If a request for accommodation is denied, this section is completed by the Deciding Official. It provides a formal record of the denial and the reasons behind it, which is important for transparency and potential appeals.
Privacy Act Statement: This statement outlines how the information collected through the accommodation process will be used, emphasizing the importance of confidentiality and the legal obligations of the employer regarding the handling of personal information.
Supplemental Attachments: Individuals may include additional documentation or explanations if there is insufficient space on the 13661 form. These attachments can provide further context or details necessary for the accommodation decision.

Understanding these accompanying forms and documents is vital for both employees seeking reasonable accommodations and the officials responsible for processing these requests. Each document contributes to a comprehensive approach that respects the rights of individuals with disabilities while ensuring that employers can fulfill their obligations under the law.

Similar forms

The Form 13661 is closely related to the Family and Medical Leave Act (FMLA) documentation. Both documents are designed to manage employee requests for accommodations or leave due to health-related issues. FMLA allows eligible employees to take unpaid leave for specific family and medical reasons, while Form 13661 focuses on reasonable accommodations for employees with disabilities. Both forms require medical documentation to support the requests, ensuring that employers have adequate information to make informed decisions regarding employee needs.

Another similar document is the Americans with Disabilities Act (ADA) request form. The ADA mandates that employers provide reasonable accommodations to qualified individuals with disabilities. Like Form 13661, the ADA request form requires detailed information about the employee's condition and the specific accommodations needed. Both documents aim to ensure that individuals can perform essential job functions while addressing their unique challenges.

The Interactive Process form is also comparable to Form 13661. This process involves a collaborative dialogue between the employer and employee to determine appropriate accommodations. Both documents emphasize the importance of communication and mutual understanding in addressing an employee's needs. The Interactive Process form, however, may not be as structured as Form 13661, which provides clear sections for documentation and decision-making.

Additionally, the Job Accommodation Network (JAN) resources share similarities with Form 13661. JAN offers guidance and information on reasonable accommodations and the ADA. While Form 13661 serves as a formal request for accommodations, JAN provides practical advice on how to implement those accommodations effectively. Both focus on improving workplace accessibility for individuals with disabilities.

The Medical Certification form used in conjunction with FMLA requests bears resemblance to Form 13661. This form requires healthcare providers to confirm the medical necessity of leave or accommodations. Similar to the medical documentation required in Form 13661, the Medical Certification form ensures that the employer receives credible information to support the employee's request. Both forms are critical in validating the need for accommodations based on health conditions.

The Employee Assistance Program (EAP) referral form is another document that relates to Form 13661. EAPs often assist employees facing personal or work-related challenges, including mental health issues. While Form 13661 focuses on reasonable accommodations for disabilities, EAP referrals can provide additional support services that may help employees manage their conditions. Both documents emphasize the importance of addressing employee well-being in the workplace.

The Disability Disclosure form is similar in that it facilitates communication between employees and employers regarding disabilities. This form allows employees to disclose their conditions and request accommodations, similar to the purpose of Form 13661. Both documents aim to create an inclusive work environment by ensuring that employees can communicate their needs effectively.

Lastly, the Return-to-Work form is akin to Form 13661 in that it addresses the needs of employees recovering from medical conditions. This form is used to assess an employee's ability to return to work after an absence due to health issues. Like Form 13661, the Return-to-Work form may require medical documentation to determine any necessary accommodations for a successful transition back to work.

Dos and Don'ts

When filling out Form 13661 for a reasonable accommodation request, it is essential to follow specific guidelines to ensure a smooth process. Here’s a helpful list of things to do and avoid:

Do provide complete and accurate information in all sections of the form.
Do describe your medical condition clearly, including how it affects your job functions.
Do specify the accommodations you are requesting based on your needs.
Do include your contact information so the Deciding Official can reach you easily.
Do submit any additional documentation as an attachment if space is limited on the form.
Don't leave any sections blank; incomplete forms can delay the process.
Don't provide genetic information unless specifically requested and allowed by law.
Don't forget to sign and date the form before submission.
Don't hesitate to ask for help if you have questions about the form or the process.

By following these guidelines, you can help ensure that your reasonable accommodation request is processed efficiently and effectively.

Misconceptions

Misconception 1: The 13661 form is only for employees with permanent disabilities.

This form is designed for any applicant or employee who requires reasonable accommodation, regardless of whether their condition is permanent or temporary. It addresses a wide range of medical conditions that may affect an individual's ability to perform their job functions.

Misconception 2: Completing the form guarantees that accommodation will be granted.

While submitting the 13661 form initiates the request process, it does not automatically ensure that accommodation will be approved. The decision depends on various factors, including the nature of the request and its feasibility.

Misconception 3: Medical documentation is optional when submitting the form.

Medical documentation is crucial for establishing the need for accommodation. Without it, the request may lack the necessary support, potentially leading to a denial.

Misconception 4: The form is too complicated to complete without legal assistance.

Although the form contains several sections, it is structured to be user-friendly. Most individuals can complete it with straightforward information about their condition and needs.

Misconception 5: Employers can request any medical information they want.

Employers are limited in the type of medical information they can request. They can only ask for information that is directly relevant to the specific accommodations being requested.

Misconception 6: Submitting the form will expose personal medical information to the entire workplace.

Information provided on the 13661 form is treated with confidentiality. It is shared only with those who need to know in order to process the accommodation request.

Misconception 7: You cannot appeal a denial of accommodation.

If a request for accommodation is denied, there are procedures in place to appeal the decision. Individuals can seek further review or clarification regarding the denial.

Misconception 8: The process for requesting accommodation is the same for all employers.

Each employer may have different procedures and policies regarding reasonable accommodation requests. It is essential to follow the specific guidelines set forth by the employer, as outlined in the 13661 form.

Key takeaways

The 13661 form is essential for individuals seeking reasonable accommodations due to a medical condition. It is divided into multiple parts, each serving a specific purpose in the accommodation process.
Part I must be filled out by the applicant or employee. This section requires detailed information about the individual’s medical condition and how it affects their job functions.
In Part II, the Deciding Official documents their assessment of the accommodation request. This part also includes space for alternative recommendations if the initial request cannot be accommodated.
Medical documentation is required in Parts III-A and III-B. Healthcare practitioners must provide information that supports the need for accommodation, including the diagnosis and its impact on major life activities.
It is crucial to provide accurate and complete information on the form. Incomplete submissions may lead to delays or denials in the accommodation process.
Individuals should not disclose any genetic information when completing the form, as mandated by the Genetic Information Nondiscrimination Act (GINA). This law restricts the collection of genetic data unless specifically allowed.
Privacy is a key concern. The information provided on the form may be shared with relevant federal, state, or local agencies under certain circumstances, but it is protected under the Privacy Act.
Returning the completed form promptly is important. Applicants can submit Part I via fax or directly to the assigned Reasonable Accommodation Coordinator to initiate the process.