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U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-6079 (Rev. 03-06)

REQUEST FOR REASONABLE ACCOMMODATION
Office Location and Address

Applicant/Employee Name

Occupational Series and Grade (e.g., GS-301-11)

Office Telephone Number

Briefly describe the medical condition requiring accommodation.

Briefly describe the specific accommodation being requested. (If additional space is needed, attach a separate sheet.)

Explain how the requested accommodation would assist you in: (1) performing the essential duties of your position, (2) using the job application process, or (3) taking advantage of a benefit or privilege offered by the office/bureau.

Requestor: Date:
U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-6079 (Rev. 03-06)

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