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The 13661 form serves as a crucial tool for individuals seeking reasonable accommodations in the workplace, particularly within the context of employment with the Internal Revenue Service (IRS). This form is divided into several parts, each designed to facilitate the request process. The first part requires the applicant, employee, or IRS official to provide essential information regarding the individual’s medical condition and how it impacts their ability to perform job functions. In the second part, the Deciding Official documents their assessment of the request, which may include alternative accommodation suggestions. Parts III-A and III-B focus on the necessary medical documentation that must be completed by a qualified health care practitioner, social worker, or rehabilitation counselor. This documentation is vital as it establishes the relationship between the medical condition and the need for accommodation. Finally, Part IV allows the Deciding Official to formally document any denial of the accommodation request. It is important to note that the form includes a Privacy Act Statement, ensuring that the information provided is handled with confidentiality and used solely for the purpose of processing the accommodation request. The form also emphasizes compliance with the Genetic Information Nondiscrimination Act (GINA), which restricts the collection of genetic information to protect individuals' privacy. Understanding the 13661 form and its components is essential for both employees and employers to ensure a fair and supportive workplace environment.

13661 Example

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

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

 

 

 

 

 

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:

 

 

 

 

Seeing/Vision

 

 

 

 

 

Hearing

 

 

 

 

 

 

 

 

 

 

 

Breathing/Respiratory

 

 

Limited to:

 

 

 

 

 

 

 

 

 

 

Speaking

 

 

Limited to:

 

 

 

 

 

 

 

 

 

 

Basic Mobility

 

 

Limited to:

 

 

 

 

Walking

 

 

 

Hours per day

 

Climbing stairs

 

 

 

Distance

 

 

 

 

 

Sitting

 

 

 

 

 

 

 

% of day

 

Standing

 

 

 

 

 

 

 

 

 

 

Secondary Mobility

 

 

Limited to:

 

 

 

 

Squatting/kneeling

 

 

 

 

 

Twisting (neck/waist)

 

 

 

Hours per day

 

Bending/stooping

 

 

 

 

 

Reaching above shoulder

 

 

 

 

 

 

 

 

 

 

Physical Exertion

 

 

Limited to:

 

 

 

 

Pushing/pulling

 

 

 

Number of pounds

 

Lifting/Carrying

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fine Motor Skills

 

 

Limited to:

 

 

 

 

Keyboard use

 

 

 

 

 

Repetitive use of hands

 

 

 

Hours per day

 

Grasping

 

 

 

 

 

Fine finger motions

 

 

 

 

 

 

 

 

 

 

Cognitive

 

 

Limited to:

 

 

 

 

Thinking

 

 

 

 

 

Learning

 

 

 

 

 

Comprehending

 

 

 

 

 

Concentrating

 

 

 

 

 

 

 

 

 

 

Caring for self

 

 

Limited to:

 

 

 

 

Self-medication/checks

 

 

 

 

 

Dressing

 

 

 

 

 

 

 

 

 

 

Mental/emotional

 

 

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

Click for 13661 File

File Breakdown

Fact Name Fact Description
Purpose The 13661 form is used to request reasonable accommodations for employees or applicants with disabilities.
Parts The form consists of four parts: Written Request, Deciding Official Documentation, Medical Documentation, and Denial of Request.
Privacy Act Statement Information collected is authorized by Section 501 of the Rehabilitation Act and may be disclosed to relevant agencies for investigations or claims.
GINA Compliance The form complies with the Genetic Information Nondiscrimination Act (GINA), prohibiting the request for genetic information unless allowed by law.
Submission Instructions Completed forms should be returned via fax or to the assigned Reasonable Accommodation Coordinator.
Medical Documentation Health Care Practitioners must complete sections that confirm the applicant's medical condition and its impact on major life activities.
Denial Process If a request is denied, the Deciding Official must document the reasons in Part IV of the form.
State-Specific Laws State laws governing reasonable accommodations may vary; refer to local regulations for specific requirements.
Importance of Completeness Failure to fully complete the form may result in a breakdown of the accommodation process and denial of the request.

Guide to Using 13661

Filling out Form 13661 is a crucial step in the process of requesting reasonable accommodation due to a medical condition. This form must be completed accurately to ensure that your request is properly documented and reviewed. Below are the steps to fill out the form effectively.

  1. Part I - Written Reasonable Accommodation Request
    • Enter your last name and first name.
    • Fill in your occupational SEID, series, and grade.
    • Provide your operating division or function.
    • Input your contact information, including office phone number, FAX number, and email address.
    • List your mailing address where you receive official correspondence.
    • Provide your manager's contact information, including their name, telephone number, and email address.
    • Describe your medical condition that requires accommodation.
    • Explain how your medical condition limits your ability to perform your current duties or access benefits of employment.
    • State the accommodations you are requesting to perform effectively.
    • Include any additional comments if necessary.
    • Sign and date the form.
  2. Part II - Deciding Official Documentation
    • Enter the name of the applicant or employee.
    • Document the date of the oral request, if different from the written request.
    • Fill in the Deciding Official's name, title, SEID, phone number, and email address.
    • Identify the job duties limited by the applicant/employee's medical condition.
    • Indicate if the limitation affects an essential function of the job.
    • Assess whether the requested accommodation will allow successful performance of essential job functions.
    • List any alternative accommodation recommendations.
    • Determine if medical documentation is needed to make a decision on the request.
    • Sign and date the form.
  3. Part III - Medical Documentation
    • Provide the name of the applicant/employee.
    • State the diagnosis related to the reasonable accommodation request.
    • Explain the impact of the medical condition on major life activities.
    • Specify the anticipated duration of the medical condition.
    • Include the name, telephone number, and best method and time to contact the health care practitioner, social worker, or rehabilitation counselor.
    • Sign and date the form.
  4. Part IV - Denial of Reasonable Accommodation Request
    • If applicable, document the denial of the reasonable accommodation request.
    • Provide a signature and date.

Once the form is completed, submit it to the appropriate contact as specified in the instructions. Ensure that any additional information or attachments are included if there is not enough space on the form itself.

Get Answers on 13661

What is the purpose of Form 13661?

Form 13661 is used to request reasonable accommodations in the workplace for individuals with disabilities. It serves as a formal document for employees, applicants, or IRS officials to detail their needs related to a medical condition that limits their ability to perform job functions. The form facilitates communication between the employee and management, ensuring that the necessary adjustments can be made to support the employee's performance and participation in the workplace.

Who should complete each part of Form 13661?

Form 13661 consists of several parts, each designated for different individuals:

  • Part I: This section should be completed by the applicant or employee requesting accommodation.
  • Part II: This part is for the Deciding Official, who evaluates the request and documents the decision.
  • Part III: Medical documentation is required from a Health Care Practitioner, Social Worker, or Rehabilitation Counselor to substantiate the request.
  • Part IV: If a request is denied, the Deciding Official completes this section to document the reasons for the denial.

What information is required in Part I of the form?

In Part I, the applicant or employee must provide personal information, including their name, contact details, and job-related information. They should describe their medical condition and how it affects their job functions. Additionally, the individual must specify the accommodations they believe would help them perform their job effectively. If there is not enough space to provide detailed information, they are encouraged to attach additional documentation.

What happens if a reasonable accommodation request is denied?

If a reasonable accommodation request is denied, the Deciding Official must complete Part IV of the form. This section documents the reasons for the denial and provides the applicant with an understanding of the decision. It is important for the employee to know their rights and options following a denial, including the possibility of appealing the decision or seeking further clarification.

What protections does GINA provide in relation to Form 13661?

The Genetic Information Nondiscrimination Act (GINA) prohibits employers from requesting genetic information about employees or their family members, with specific exceptions. When completing Form 13661, individuals should refrain from providing any genetic information unless it is explicitly allowed under GINA. This ensures that personal medical information is protected while still allowing for necessary accommodations to be made based on legitimate medical needs.

Common mistakes

Filling out Form 13661 can be a critical step in obtaining reasonable accommodations, but many people make mistakes that can delay or complicate the process. Here are nine common errors to avoid.

One frequent mistake is incomplete information. Applicants often fail to provide all required details, such as their contact information or medical condition. Omitting this information can lead to processing delays. Ensure that every section is fully filled out before submission.

Another common issue is not clearly describing the medical condition. When detailing the condition that necessitates accommodation, vague descriptions do not help decision-makers understand the need. Be specific about how the condition affects job performance and daily activities.

Some applicants neglect to specify the accommodation requested. Simply stating that an accommodation is needed without providing examples can lead to confusion. Clearly outline what adjustments would help you perform your job effectively.

Additionally, many individuals fail to attach necessary medical documentation. If the medical condition is not obvious, supporting documents from a healthcare professional are essential. Without this documentation, the request may be denied.

Another mistake involves not keeping copies of submitted forms. Applicants often overlook the importance of maintaining records of their requests. Keeping a copy can be invaluable if there are questions or disputes later on.

Some people also make the error of submitting the form to the wrong contact person. Ensure that you send your request to the designated Reasonable Accommodation Coordinator. Sending it to the wrong office can result in unnecessary delays.

Another common oversight is misunderstanding the submission method. Some applicants fail to follow the instructions for faxing or emailing the form. Be sure to use the correct method as specified in the guidelines to avoid complications.

Moreover, applicants sometimes do not provide alternative accommodation suggestions. If the requested accommodation cannot be granted, having alternatives ready can facilitate the process. Consider what other adjustments might work for you.

Finally, many individuals do not take the time to review their forms before submission. Errors in spelling or grammar may seem minor, but they can affect the clarity of your request. A thorough review can help ensure that your message is communicated effectively.

Avoiding these mistakes can make a significant difference in the outcome of your reasonable accommodation request. Take the time to fill out Form 13661 carefully and completely.

Documents used along the form

The 13661 form is a key document used to request reasonable accommodations in the workplace. Alongside this form, several other documents are commonly utilized to support the accommodation process. Each of these documents serves a distinct purpose and helps ensure that the accommodation request is properly evaluated and documented.

  • Document 12986 – Nondisclosure of GINA Protected Information: This document informs individuals about the Genetic Information Nondiscrimination Act (GINA), which restricts the collection of genetic information from employees and their family members. It outlines the exceptions applicable under specific circumstances, such as the Family and Medical Leave Act (FMLA) and the Rehabilitation Act.
  • Medical Documentation (Part III-A): This section must be completed by a healthcare practitioner, social worker, or rehabilitation counselor. It provides necessary medical information to support the reasonable accommodation request, including details about the individual's diagnosis and how it affects major life activities.
  • Medical Documentation (Limitations Worksheet - Part III-B): This worksheet is also completed by a healthcare professional. It focuses on the specific limitations caused by the medical condition and is used to further clarify the need for accommodations.
  • Deciding Official Documentation (Part II): This document is filled out by the deciding official who reviews the accommodation request. It tracks essential information about the applicant's limitations and the impact on job functions, as well as any alternative accommodations considered.
  • Denial of Reasonable Accommodation Request (Part IV): If a request for accommodation is denied, this section is completed by the deciding official. It documents the reasons for denial and is crucial for transparency in the decision-making process.
  • Privacy Act Statement: This statement explains how the information collected through the reasonable accommodation process will be used and the legal authority behind it. It assures individuals that their information will be handled with care and confidentiality.
  • FMLA Certification: When an employee requests leave under the Family and Medical Leave Act, this certification may be required. It provides the employer with necessary medical information to assess the leave request based on the employee’s serious health condition.
  • Additional Attachments: If there is insufficient space on any part of the 13661 form, applicants or officials may include additional documentation as attachments. This ensures that all relevant information is captured in the accommodation request process.

These documents collectively support the reasonable accommodation process, ensuring that requests are thoroughly reviewed and that individuals receive the necessary support in the workplace. Proper completion and submission of these forms are essential for a smooth and effective accommodation experience.

Similar forms

The Form 13661, which is a Reasonable Accommodation Request, shares similarities with several other documents that address employee rights and accommodations in the workplace. Below is a list of these similar documents and how they relate to Form 13661.

  • ADA Accommodation Request Form: This form is used under the Americans with Disabilities Act to request accommodations for employees with disabilities, similar to how Form 13661 facilitates requests for reasonable accommodations.
  • FMLA Certification Form: Like Form 13661, this document allows employees to provide medical information to support their request for leave due to serious health conditions, ensuring that the employer can assess the need for leave.
  • Job Accommodation Network (JAN) Resources: JAN provides information and resources for requesting workplace accommodations, paralleling the guidance offered in Form 13661 for employees seeking modifications to their work environment.
  • Interactive Process Documentation: This document outlines the steps taken during discussions between the employer and employee regarding accommodations, much like the documentation required in Form 13661.
  • Medical Release Form: This form allows employers to obtain medical information from healthcare providers, similar to how Form 13661 collects necessary medical documentation to support accommodation requests.
  • Disability Disclosure Form: Employees may use this form to disclose their disabilities to their employers, akin to the information gathered in Form 13661 to establish the need for accommodations.
  • Return to Work Certification: This document is completed by healthcare providers to certify that an employee is fit to return to work, which aligns with the medical documentation components of Form 13661.

Dos and Don'ts

When filling out the 13661 form, it is important to follow certain guidelines to ensure your request for reasonable accommodation is processed smoothly. Here are five things you should and shouldn't do:

  • Do provide accurate and complete information about your medical condition.
  • Do specify how your condition affects your job functions.
  • Do include your preferred method and time for contact.
  • Don't leave any sections blank unless absolutely necessary.
  • Don't include any genetic information that is not relevant to your request.

Following these guidelines will help ensure that your request is clear and that you receive the necessary accommodations in a timely manner.

Misconceptions

Misconceptions about the 13661 form can lead to confusion regarding its purpose and use. Below are ten common misconceptions along with clarifications.

  • The 13661 form is only for employees with permanent disabilities. This form can be used by applicants and employees with temporary or permanent disabilities seeking reasonable accommodations.
  • Submitting the form guarantees approval of the accommodation request. While the form initiates the process, approval depends on various factors, including the nature of the request and the employer's assessment.
  • Medical documentation is not required. Medical documentation is necessary to support the request if the disability or need for accommodation is not obvious.
  • All medical information must be disclosed. The Genetic Information Nondiscrimination Act (GINA) protects individuals from having to disclose genetic information when submitting medical documentation.
  • The form is only relevant for IRS employees. While it is designed for IRS employees, similar forms exist for other federal agencies, reflecting a broader application.
  • Reasonable accommodation requests can be made verbally. Although verbal requests can occur, the 13661 form must be completed to document the request formally.
  • There is no deadline for submitting the form. Timeliness is essential; requests should be submitted as soon as the need for accommodation is identified to facilitate the process.
  • All accommodations requested will be granted. Employers are required to consider requests but are not obligated to grant every accommodation, especially if it imposes undue hardship.
  • Employees must provide their entire medical history. Only relevant medical information related to the accommodation request is necessary, not the entire medical history.
  • Failure to complete the form will not impact the request. Incomplete forms can lead to delays or denials in the reasonable accommodation process.

Key takeaways

When filling out and using the 13661 form for reasonable accommodation requests, consider the following key points:

  • Complete All Parts: Ensure that all relevant sections of the form are filled out completely. Incomplete forms can lead to delays or denials.
  • Provide Detailed Information: Clearly describe your medical condition, how it affects your job functions, and the specific accommodations you are requesting.
  • Use Attachments if Necessary: If there is not enough space on the form, attach additional information. This can help clarify your request.
  • Understand Privacy Regulations: Be aware that the information you provide is protected under the Privacy Act and GINA, and should not include genetic information unless specifically allowed.
  • Follow Submission Guidelines: Submit the completed form to the designated fax number or reasonable accommodation coordinator as instructed.
  • Medical Documentation: If required, ensure that any medical documentation is completed by a qualified healthcare practitioner and clearly outlines the relationship between your condition and the requested accommodation.
  • Timely Responses: Be prepared for potential follow-up questions from the Deciding Official or healthcare practitioner regarding your condition or accommodation request.
  • Know Your Rights: Familiarize yourself with the Rehabilitation Act and ADAAA provisions to understand your rights regarding reasonable accommodations.

Act promptly to ensure that your request is processed efficiently. Delays in submission can hinder your ability to receive necessary accommodations.