SECNAV 12306/1 Confirmation of Reasonable Accommodation Request

OMB 0703-0063 Exp 31 MAR 2025
SECNAV RCS 12306-1 Exp 31 MAR 2025
SECNAVINST 12713.14

CUI (when filled in)

CONFIRMATION OF REASONABLE ACCOMMODATION REQUEST
PRIVACY ACT STATEMENT
Authority: 5 U.S.C. 301; 5 U.S.C. Chapters 11, 13, 29, 31, 33, 41, 43, 51, 53, 55, 61, 63, 72, 75, 83, 99; 5 U.S.C. 7201; 29 USC 791; 10 U.S.C. 136;
E.O. 9830, as amended; 29 U.S.C. 79; 29 C.F.R. 1614.601, EEO Group Statistics; 29 CFR 1630.14, Medical Examinations and Inquiries Specifically
Permitted; SECNAV Instruction 12713.14, Equal Employment Opportunity; and E.O. 9397 (SSN), as amended, and System of Records Notice (SORN)
N12293-1.
Purpose(s): To provide relevant officials with the information to track, monitor, review, and process requests for reasonable accommodation.
Routine Uses(s): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, these records
contained therein may specifically be disclosed outside the Department of Defense (DoD) as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:
To the appropriate officials for the purpose of processing or responding to the request for reasonable accommodation and/or decisions related to such
request. To officials and employees of the Equal Employment Opportunity Commission and/or other appropriate third parties responsible for
investigating or adjudicating any cases that may result from a reasonable accommodation request. To unions recognized as exclusive bargaining
representatives under the Civil Service Reform Act of 1978, 5 U.S.C. §§ 7111 and 7114, the Merit Systems Protection Board, the Office of the Special
Counsel, arbitrators, the Federal Labor Relations Authority, and other parties responsible for the administration of the Federal labor-management
program for the purpose of processing any corrective actions, grievances, or conducting administrative hearings or appeals. To the Office of Personnel
Management (OPM), Office of Workers' Compensation, and Department of Veterans Affairs for the purpose of addressing civilian pay and leave,
benefits, retirement deduction, and any other obligations. To an employee's private treating physician and to medical personnel retained by the DON to
provide medical services in connection with an employee's health or physical condition related to employment. To the Occupational Safety and Health
officials when needed to perform their duties.
Disclosure: Completion of this form is voluntary; however, failure to provide the requested information may result in an inability to process your
reasonable accommodation request.
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, OMB 0703-0063, is estimated to average 20 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control
number.
LOCATION (Physical Location of Requested Reasonable Accommodation):

REQUEST TYPE:

DATE (DDMMMYYYY):

☐

My Own Behalf

On Behalf Of

PART I Requestor's Information (To be completed by Requestor or "On Behalf Of" Requestor)
1.

NAME (Last, First, Middle Initial):

2.

ORGANIZATION/DEPARTMENT:

3.

UNIT IDENTIFICATION CODE (UIC):

4.

DoD ID NUMBER (for employees only):

5.

PHONE:

6.

ALTERNATE PHONE:

7.

OFFICIAL E-MAIL ADDRESS:

8.

9. DESIGNATION OF PERSON

☐

EMPLOYEE

APPLICANT

10.

JOB TITLE AND PAY PLAN/SERIES/GRADE:

OFFICIAL MAILING ADDRESS:

CONTRACTOR

PART II Details for Reasonable Accommodation (To be completed by Requestor or "On Behalf Of" Requestor)
11. DESCRIBE ANY IMPACT OF YOUR LIMITATIONS ON THE PERFORMANCE OF YOUR DUTIES OR ACCESSING A BENEFIT/PRIVILEGE
OF EMPLOYMENT:

SECNAV 12306/1 (REV. OCT 2019)

CUI (when filled in)

Controlled By: DON OEEO
CUI Category: HLTH/PRVCY/PII
LDC: FEDCON
POC: DONOEEO@us.navy.mil

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CUI (when filled in)

OMB 0703-0063 Exp 31 MAR 2025
SECNAV RCS 12306-1 Exp 31 MAR 2025
SECNAVINST 12713.14

12. DESCRIBE ANY ACCOMMODATION YOU BELIEVE WOULD ASSIST YOU IN THE PERFORMANCE OF YOUR DUTIES OR ACCESSING A
BENEFIT/PRIVILEGE OF EMPLOYMENT:

13. IF REQUEST IS DUE TO A WORK-RELATED INJURY, PLEASE PROVIDE WORKERS' COMPENSATION CLAIM #:

14. DESCRIBE THE NATURE OF YOUR MEDICAL CONDITION AND YOUR WORK-RELATED LIMITATIONS (include if limitations are permanent or
temporary):

I certify that the statements and information contained in this document and any attachments are true and complete to the best of my knowledge. I
hereby give permission to release any information contained in this request to authorized officials with a need to know.
PART III Certification of Requestor and/or Designated Appointee or Approving Official
15. REQUESTOR'S PRINTED NAME:

16. REQUESTOR'S SIGNATURE:

17. DATE (DDMMMYYYY):

18. SUPERVISOR'S PRINTED NAME:

19. SUPERVISOR'S SIGNATURE:

20. DATE (DDMMMYYYY):

21. SUPERVISOR'S E-MAIL ADDRESS:

22. SUPERVISOR'S PHONE NUMBER:

The signature above acknowledges receipt of this request for accommodation and all attachments if any.

SECNAV 12306/1 (REV. OCT 2019)

CUI (when filled in)

Controlled By: DON OEEO
CUI Category: HLTH/PRVCY/PII
LDC: FEDCON
POC: DONOEEO@us.navy.mil

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CUI (when filled in)

OMB 0703-0063 Exp 31 MAR 2025
SECNAV RCS 12306-1 Exp 31 MAR 2025
SECNAVINST 12713.14

INSTRUCTIONS FOR COMPLETING THE CONFIRMATION OF REASONABLE ACCOMODATION REQUEST FORM
Notes:

• The form can be completed by typing in the text fields/signing digital signature. For those who do not have access to a computer, the form
can be completed by printing in the text fields/signing wet signature.
• Completed forms should be submitted to the servicing Reasonable Accommodation Point of Contact (RA POC) for processing and record
keeping purposes.
• Please review the Privacy Act Statement and the Agency Disclosure Notice that are printed at the top of this form.
• For the purposes of the form, `Requestor' is defined as the person requesting the reasonable accommodation, or a designated appointee
acting on behalf of the Requestor.
• Attachments supporting the Reasonable Accommodation Request may be included by the Requestor or Designated Appointee.
COMPLETION OF THE FORM
• The Physical Location of the Requested Reasonable Accommodation should be entered in the `LOCATION' block.
• The submission date of the Reasonable Accommodation Request form should be entered in the specified format in the `DATE' block.
• In the `REQUEST TYPE' block, indicate whether the request is submitted by the Requestor (`My Own Behalf') or by a designated appointee
acting on behalf of the Requestor (`On Behalf Of') by selecting the appropriate box.

Part I: Requestor's Information

Part II: Details for Reasonable Accommodation

Part I should be filled out and completed by the Requestor or "On Behalf
Of" the Requestor. Consult with the supervisor and/or the servicing
Reasonable Accommodation Point of Contact when needed.

Part II should be filled out and completed by the Requestor or "On Behalf
Of" the Requestor.

1. Name (Last, First, Middle Initial): As stated.

11. Describe any impact of your limitations on the performance of your
duties or accessing a benefit/privilege of employment: As stated.

2. Organization/Department: For employees, the requestor's current
organization/department name. For applicants, the organization/
department name of the position sought.

12.Describe any accommodation that you believe would assist you in the
performance of duties or accessing a benefit/privilege of employment:
As stated.

3. Unit Identification Code (UIC): For employees, the five-digit code
associated with requestor's current employing organization. For
applicants, the five-digit code associated with the organization of the
position sought.

13. If the request is due to a work-related injury, the requestor shall provide
the Workers' Compensation claim number: Enter the Workers'
Compensation claim number if applicable. If the request is not due to a
work-related injury, please enter "N/A," or the field can stay blank.

4. DoD ID Number: For employees only, please enter in your 10-digit DoD/ 14. Describe the nature of your medical condition and the work-related
EDIPI Number. For employees that do not have a DoD ID Number/EDIPI
limitations (include if limitations are permanent or temporary): As stated.
Number, please enter your Employee ID number.
Part III: Certification of Requestor and/or Designated Appointee or
Approving Official
5. Phone: As stated.
6. Alternate Phone: As stated.

Part III should be filled out and digitally signed by the Requestor (or their
Designated Appointee) and (Requestor's Supervisor). Please include all
information requested:

7. Official Email Address: For employees, the requestor's work email
address should be used. For applicants, the requestor's preferred email
address should be used.
15. Requestor's Printed Name: As stated.
8. Job Title and Pay Plan/Series/Grade: If the requestor is an employee,
the official work title, pay plan/series/grade information of the
Requestor. If the requestor is an applicant, the official job title and pay
plan/series/grade information of the position sought.

16. Requestor's Signature: Typing/signing a digital signature, or printing/
signing a wet signature is permitted.
17. Date: Use `DDMMMYYYY' format.

9. Designation of Person: Indicate whether the Requestor is an Employee, 18. Supervisor's Printed Name: As stated.
Applicant or Contractor.
19. Supervisor's Signature: Typing/signing a digital signature, or printing/
signing a wet signature is permitted.
10. Official Mailing Address: For employees, the requestor's work mailing
address should be used. For applicants, the requestor's preferred
mailing address should be used.
20. Date: Use `DDMMMYYYY' format.
21. Supervisor's E-mail Address: The Supervisor's work email address
should be used.
22. Supervisor's Phone Number: work phone number should be used

SECNAV 12306/1 (REV. OCT 2019)

CUI (when filled in)

Controlled By: DON OEEO
CUI Category: HLTH/PRVCY/PII
LDC: FEDCON
POC: DONOEEO@us.navy.mil

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