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Blank 13661 Form

The 13661 form is a document used to request reasonable accommodations in the workplace for individuals with disabilities. This form is essential for applicants and employees seeking modifications that enable them to perform their job duties effectively. It includes sections for personal information, medical documentation, and the decision-making process regarding accommodation requests.

Outline

The 13661 form serves as a critical tool in the process of requesting reasonable accommodations for individuals with disabilities within the workplace. Designed for use by applicants, employees, and IRS officials, this form is divided into several parts, each serving a distinct purpose. Part I allows the individual seeking accommodation to provide essential information, including their medical condition and how it affects their job functions. This section emphasizes the importance of clearly articulating the accommodations needed to perform effectively. Following this, Part II is intended for the Deciding Official, who evaluates the request and documents their findings, ensuring that decisions are made based on comprehensive information. Medical professionals, such as health care practitioners or rehabilitation counselors, contribute in Parts III-A and III-B by providing necessary medical documentation that supports the accommodation request. In cases where a request is denied, Part IV allows for documentation of the reasons for the denial, ensuring transparency in the process. Additionally, the form includes a privacy statement, underscoring the importance of confidentiality and compliance with regulations like the Genetic Information Nondiscrimination Act (GINA). Understanding the structure and purpose of the 13661 form is vital for both employees seeking accommodations and the officials responsible for processing these requests.

Sample - 13661 Form

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

Click for PDF

Form Information

Fact Name	Description
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: the accommodation request, documentation by the deciding official, medical documentation, and denial documentation.
Privacy Act Statement	The form includes a statement explaining how the information collected will be used and protected under the Privacy Act.
Medical Documentation Requirement	Healthcare practitioners must provide documentation that outlines the individual's medical condition and how it affects their work capabilities.
GINA Compliance	The form adheres to the Genetic Information Nondiscrimination Act (GINA), ensuring that genetic information is not requested unless permitted by law.
Legal Basis	The form is governed by Section 501 of the Rehabilitation Act, which mandates reasonable accommodations for individuals with disabilities.
Submission Guidelines	Completed forms should be submitted via fax or to the assigned Reasonable Accommodation Coordinator for processing.
Consequences of Incomplete Forms	Failure to complete the form or provide necessary documentation may result in a denial of the accommodation request.

Detailed Guide for Filling Out 13661

Completing Form 13661 requires careful attention to detail to ensure that all necessary information is accurately provided. This form is essential for documenting a request for reasonable accommodation. Following the steps outlined below will help streamline the process and facilitate a timely response.

Begin with Part I. Fill in your Last Name and First Name in the designated fields.
Provide your Occupational SEID, Series, and Grade information.
Indicate your Operating Division/Function.
Complete the Contact Information section, including your office phone number, FAX number, Post of Duty (POD), Tour of Duty/Shift, email address, and preferred method/time to contact.
Enter your Mailing Address, ensuring to include all relevant details such as Address 1, Address 2, Room Number, Mail Stop, City, State, and ZIP code.
Fill in your Manager's Contact Information, including the manager's name, telephone number, and email address.
Describe your Medical Condition that requires accommodation in the appropriate section.
Explain how your medical condition affects your Job Functions and limits your ability to perform your duties.
Specify the Accommodation Requested that would assist you in performing effectively.
Provide any Additional Comments you feel are necessary.
Sign and date the form to affirm that all statements are true to the best of your knowledge.
Return Part I to the designated FAX number or the assigned Reasonable Accommodation Coordinator.

After submitting Part I, the Deciding Official will review your request and may need to complete Parts II and III. These sections require additional documentation and input from health care professionals, which may be necessary for your accommodation process.

Obtain Answers on 13661

What is the purpose of Form 13661?
Form 13661 is designed to facilitate requests for reasonable accommodations by applicants or employees who have a disability. The form allows individuals to document their medical condition, the limitations it imposes on their job functions, and the specific accommodations they are seeking. This process ensures that the needs of individuals with disabilities are adequately considered and addressed in the workplace.
Who should complete the different parts of Form 13661?
The form is divided into several parts, each designated for specific individuals:
- Part I: To be completed by the applicant or employee, detailing their request for reasonable accommodation.
- Part II: This section is for the Deciding Official to document their assessment of the request.
- Part III: Medical documentation must be filled out by a qualified Health Care Practitioner, Social Worker, or Rehabilitation Counselor.
- Part IV: Should be completed by the Deciding Official if the request for accommodation is denied.
What kind of information is required on the form?
Form 13661 requires various types of information, including:
- Personal details of the applicant or employee, such as name, contact information, and job title.
- A description of the medical condition that necessitates the accommodation.
- Specific job functions that are affected by the medical condition.
- The type of accommodation requested to assist in performing job duties.
It is important to provide complete and accurate information to avoid delays in the accommodation process.
What happens if the request for accommodation 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 the denial and may provide information on alternative accommodations considered. The applicant or employee should be informed of their right to appeal the decision or seek further clarification.
How does the Genetic Information Nondiscrimination Act (GINA) relate to Form 13661?
GINA prohibits employers from requesting or requiring genetic information about employees or their family members. When completing Form 13661, individuals are advised not to include any genetic information unless specifically allowed under exceptions related to the Family and Medical Leave Act (FMLA) or the Rehabilitation Act. This ensures compliance with GINA while still allowing for necessary medical documentation to support reasonable accommodation requests.

Common mistakes

Completing the 13661 form can be a straightforward process, but many individuals make common mistakes that can hinder their reasonable accommodation requests. Understanding these pitfalls can help ensure a smoother experience.

One frequent error is incomplete information. Applicants often neglect to fill in all required fields, such as their contact information or details about their medical condition. Missing information can delay the processing of the request and may even result in a denial. Always double-check that every section is filled out accurately.

Another mistake involves insufficient medical documentation. When submitting medical information, it's crucial to provide clear and comprehensive documentation that supports the need for accommodation. Vague descriptions or lack of a diagnosis can lead to confusion and may cause the request to be rejected. Ensure that the medical documentation clearly links the condition to the requested accommodations.

Many applicants also fail to articulate how their medical condition affects job functions. It's essential to explain specifically how the condition limits the ability to perform essential job duties. A generic statement won't suffice; detailed descriptions help decision-makers understand the necessity of the accommodation.

Some individuals overlook the importance of alternative accommodations. When submitting the request, it’s beneficial to suggest multiple options for accommodations. This flexibility can make it easier for the deciding official to approve a solution that works for both parties.

Another common oversight is not providing a preferred method of contact. Applicants should indicate how and when they can be reached, whether by phone or email. This information facilitates communication and ensures that any follow-up questions can be addressed promptly.

Additionally, failing to review the Privacy Act Statement can lead to misunderstandings about how personal information will be used. Being aware of privacy protections helps applicants feel more secure when disclosing sensitive medical information.

Finally, some individuals mistakenly believe that they can submit the form without a signature. An unsigned form is incomplete and cannot be processed. Always remember to sign and date the form before submission to validate the request.

By avoiding these common mistakes, applicants can enhance their chances of successfully obtaining the reasonable accommodations they need.

Documents used along the form

The 13661 form is a key document for requesting reasonable accommodations in the workplace. However, several other forms and documents are often used alongside it to ensure a smooth process. Here’s a brief overview of those documents:

Nondisclosure of GINA Protected Information: This document informs individuals about the Genetic Information Nondiscrimination Act (GINA). It explains the restrictions on collecting genetic information from employees and their family members, ensuring compliance with the law.
Family and Medical Leave Act (FMLA) Documentation: This form is used when an employee requests leave due to their own serious health condition or to care for a family member. It helps employers manage and verify FMLA requests while ensuring employee rights are protected.
Medical Documentation (Part III-A): Completed by a healthcare practitioner, this document provides necessary medical information about the employee's condition. It establishes the link between the medical condition and the need for accommodation.
Limitations Worksheet (Part III-B): This is an extension of the medical documentation. It details the specific limitations caused by the medical condition, helping decision-makers understand the impact on job performance.
Deciding Official Documentation (Part II): This form is filled out by the Deciding Official to track the accommodation request process. It includes information about the employee's limitations and the impact on their job functions.
Denial of Reasonable Accommodation Request (Part IV): If a request is denied, this form documents the reasons for the denial. It ensures transparency and provides the employee with an understanding of the decision.
Privacy Act Statement: This statement outlines how the information collected will be used and protected. It assures employees that their personal data will be handled responsibly.
Additional Attachments: Employees may submit extra documents if there isn't enough space on the main forms. These attachments can provide further details relevant to the accommodation request.
Job Description: A copy of the job description may accompany the request to clarify the essential functions of the position. This helps in assessing the need for accommodations based on job requirements.

Using these forms and documents together with the 13661 form can streamline the reasonable accommodation process. Each document plays a vital role in ensuring that requests are handled fairly and efficiently, while also protecting the rights of employees.

Similar forms

The Form 13661, which is a Reasonable Accommodation Request Document, shares similarities with various other forms and documents used in employment and disability contexts. Below is a list of ten documents that are comparable to Form 13661, along with a brief explanation of how they are similar.

ADA Accommodation Request Form: Like Form 13661, this document is used to request accommodations under the Americans with Disabilities Act (ADA). Both forms require information about the individual's disability and the specific accommodations needed to perform job functions.
Family and Medical Leave Act (FMLA) Certification Form: This form is used to certify the need for leave due to a serious health condition. Similar to Form 13661, it requires medical documentation to support the request, ensuring that the employee's needs are clearly communicated.
Employee Medical Leave Request Form: This document allows employees to formally request medical leave. Like Form 13661, it often requires detailed information about the medical condition and its impact on work duties.
Return to Work Form: After a medical leave, this form is used to assess an employee's readiness to return to work. It parallels Form 13661 in that it seeks medical input regarding the employee's ability to perform job functions safely and effectively.
Job Accommodation Network (JAN) Consultation Request: This request form is used to consult with JAN for guidance on workplace accommodations. It shares similarities with Form 13661 in its focus on identifying and documenting the need for reasonable accommodations.
Disability Verification Form: This document is used to verify an employee's disability status. Like Form 13661, it requires input from healthcare professionals to confirm the disability and its implications for job performance.
Workplace Safety Assessment Form: This form evaluates safety concerns related to an employee's medical condition. Similar to Form 13661, it focuses on how a medical condition affects job performance and workplace safety.
Interactive Process Documentation: This document records discussions between employers and employees regarding accommodations. It is similar to Form 13661 in that both aim to document the process of identifying and implementing necessary accommodations.
Medical Release Form: This form allows employers to obtain medical information from healthcare providers. Like Form 13661, it emphasizes the importance of medical documentation in the accommodation process.
Disability Employment Policy Acknowledgment Form: This document is used to confirm an employee's understanding of their rights under disability employment policies. It relates to Form 13661 by reinforcing the importance of reasonable accommodations in the workplace.

Dos and Don'ts

When filling out the 13661 form for a reasonable accommodation request, it is essential to follow certain guidelines to ensure your application is processed smoothly. Here are some important dos and don’ts:

Do provide accurate and complete information in all sections of the form.
Do describe your medical condition clearly and how it affects your job functions.
Do specify the accommodations you believe will help you perform your job effectively.
Do return the completed form to the designated fax number or reasonable accommodation coordinator.
Do attach any additional information if you run out of space on the form.

Don't include any genetic information, as it is prohibited under GINA.
Don't leave any sections blank; if information is not applicable, indicate that clearly.
Don't provide excessive medical documentation; only include what is necessary to support your request.
Don't forget to sign and date the form before submission.

Following these guidelines will help ensure that your reasonable accommodation request is processed efficiently and effectively.

Misconceptions

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

This is not true. The 13661 form is designed for any applicant or employee who requires a reasonable accommodation due to a disability, regardless of whether that disability is visible or not. The process is inclusive and aims to support individuals with a range of conditions.

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

While submitting the form is an important step, it does not automatically ensure that the requested accommodation will be approved. The decision is made based on various factors, including the nature of the request and the ability of the accommodation to meet the needs of the employee while maintaining workplace efficiency.

Misconception 3: Providing medical documentation is optional.

In fact, providing medical documentation is often a necessary part of the process. The documentation helps to establish the need for accommodation and must be relevant to the specific limitations caused by the disability. Without sufficient medical information, the request may be denied or delayed.

Misconception 4: The information shared on the form is not protected.

This is a common misunderstanding. The information provided on the 13661 form is protected under privacy laws. Employers are required to handle this sensitive information with care, ensuring that it is only shared with individuals who need to know for the purpose of processing the accommodation request.

Key takeaways

Complete all relevant sections of the 13661 form accurately to ensure a smooth reasonable accommodation request process.
Use attachments if additional space is needed. Each part of the form has specific requirements, and extra information may be necessary.
Medical documentation must clearly establish the disability and its impact on job functions. This information is crucial for the decision-making process.
Failure to provide complete information can hinder the accommodation process. Ensure all required documentation is submitted to avoid delays.