Help Desk Rehabilitation Counselor

Private and Confidential – To protect your privacy, only submit this form as part of your response to an applicant help desk ticket. See below for additional information. Reasonable Accommodation Request Form

Complete and submit by the Job Announcement closing date or other specified time frame, if provided. Full Name: Date:

Last First Middle Initial

Mailing Address:

Street City State Zip Code

Email Address:

Phone Number(s):

Job Announcement Number: Claimed disability:

Accommodation requested: (describe the specific assessment accommodation that you are requesting) Documentation: You must provide documentation from an appropriate professional such as a doctor, rehabilitation counselor, or vocational counselor, concerning your asserted impairment and functional limitations as they pertain to the online assessment process. Note: Your failure to provide supporting documentation may result in a delay or the inability to grant your request. Process: Your request will be evaluated by the USA Hire Reasonable Accommodations team, in cooperation with you, to determine an appropriate accommodation for the online assessments for your asserted impairment; however, this will not be a generalized determination that you are a qualified individual with a disability under the Rehabilitation Act and the Americans with Disability Act for purposes of job accommodations. You will be contacted via the email address or phone number you provided above. Complete this form and attach it to your help ticket. Please also remember to include your supporting documentation when replying. If you do not have a help ticket, you can create one using this link: https://apply.usastaffing.gov/HelpTicket Note: This Request Form contains information intended only for the use of the individual or entity named above. If the reader of this form is not the intended recipient or the employee or agent responsible for delivering it to the intended recipient, any dissemination, publication or copying of this form is strictly prohibited. If you received this form in error, please notify the sender immediately.