The National Science Foundation
Office of Equity and Civil Rights
CONFIRMATION OF REQUEST FOR REASONABLE ACCOMMODATION
1.
Applicant’s or Employee’s Name A pplicant’s or Employee’s Telephone No.
Date of Request ________________ ________________________
Employee’s Office
2. TYPE OF ACCOMMODATION REQUESTED, IF KNOWN. (Be as specific as
possible, e.g., assistive technology, reader, interpreter, schedule change)
3. REASON FOR REQUEST.
If accommodation is time sensitive, please explain:
Return Form to Disability Program Manager
(Disability Program Manager will assign number)
4. Log No.:___________________________
Privacy Act Statement:
The Rehabilitation Act of 1973, 29 U.S.C. section 791, and Executive Order 13164 authorize collection of
this information. The primary use of this information is to consider, decide, and implement requests for
reasonable accommodation. Additional disclosures of the information may be: To medical personnel to
meet a bona fide medical emergency; to another Federal agency, a court, or a party in litigation before a
court or in an administrative proceeding being conducted by a Federal agency when the Government is a
party to the judicial or administrative proceeding; to a congressional office from the record of an individual
in response to an inquiry from the congressional office made at the request of the individual; and to an
authorized appeal grievance examiner, formal complaints examiner, administrative judge, equal
employment opportunity investigator, arbitrator or other duly authorized official engaged in investigation or
settlement of a grievance, complaint or appeal filed by an employee.
EEOC Form 557 (Revised 12/21)
