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U.S. USDA Form usda-ree-172 United States Department of Agriculture Research Education and Economics Agencies REE-172 Rev. 09/2002 REQUEST FOR REASONABLE ACCOMMODATION 1. Date of request 2. Applicant or employee name 3. Telephone number 5. Employee s office 6. Type of accommodation requested be specific 7. Reason for request 8. If accommodation is time sensitive please explain This request form shall be given to your immediate supervisor and a copy sent to the Mission Area/Agency Disability Program Manager. This form is necessary for record keeping purposes only and will not delay the processing of your initial request. Sue Dixon ARS Civil Rights Staff 1400 Independence Ave. SW Room 3552-South Washington DC 20250 9. Signature of Applicant or Employee 10. Date REASONABLE ACCOMMODATION INFORMATION To Be Completed by Supervisor 1. Name of individual requesting accommodation 2. Office of the requesting individual 3. Reasonable accommodation Check one Approved 4a* Position title Denied If denied attach copy of he Denial of Accomodation Request form - Form REE-173 5. Date accommodation was requested referred or denied provided 9. If time frames outlined in the reasonable accommodation procedures were not met please explain why 10. Job held or desired by individual requesting accommodation include occupation series grade level and office 11. Type s of accommodation 13. Was medical information required to process this request If yes explain* 14. Cost of accommodation if any 16. Signature of Supervisor 15. Sources of technical assistance if any consulted Job Accommodation Network family member rehabilitation counselor other 17. Date of request 2. Applicant or employee name 3. Telephone number 5. Employee s office 6. Type of accommodation requested be specific 7. Reason for request 8. If accommodation is time sensitive please explain This request form shall be given to your immediate supervisor and a copy sent to the Mission Area/Agency Disability Program Manager. Reason for request 8. If accommodation is time sensitive please explain This request form shall be given to your immediate supervisor and a copy sent to the Mission Area/Agency Disability Program Manager. This form is necessary for record keeping purposes only and will not delay the processing of your initial request. This form is necessary for record keeping purposes only and will not delay the processing of your initial request. Sue Dixon ARS Civil Rights Staff 1400 Independence Ave. SW Room 3552-South Washington DC 20250 9. Signature of Applicant or Employee 10. Sue Dixon ARS Civil Rights Staff 1400 Independence Ave. SW Room 3552-South Washington DC 20250 9. Signature of Applicant or Employee 10. Date REASONABLE ACCOMMODATION INFORMATION To Be Completed by Supervisor 1. Name of individual requesting accommodation 2. Date REASONABLE ACCOMMODATION INFORMATION To Be Completed by Supervisor 1. Name of individual requesting accommodation 2. Office of the requesting individual 3. Reasonable accommodation Check one Approved 4a* Position title Denied If denied attach copy of he Denial of Accomodation Request form - Form REE-173 5.

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