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U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-6081 (Rev. 03-06)

DENIAL OF REASONABLE ACCOMMODATION REQUEST

Name of Individual Requesting Accommodation: 1. Type(s) of Reasonable Accommodation Requested:

2. Request for Accommodation Denied Because (may check more than one): Accommodation ineffective Accommodation would cause undue hardship Medical documentation inadequate Accommodation would require removal of an essential function Accommodation would require lowering of performance/production standard Other (please specify) 3. Detailed reason(s) for the denial of the accommodation (Must be specific, e.g., why accommodation is ineffective or causes undue hardship):

4. If the requestor proposed one type of reasonable accommodation and the request is denied, and rejected an offer of an alternative accommodation, explain the reason for denial of the original requested accommodation and how the offered alternative accommodation would be effective.

Name & Title of Decision Maker: Signature of Decision Maker: Date Reasonable Accommodation Denied:

If an individual wishes to request reconsideration of this decision, s/he may take the following steps: · · ask the decision maker, in writing within five (5) business days of receiving the decision to deny, to reconsider the denial and provide additional supporting information; if the decision maker does not reverse the decision, the individual may appeal the decision, in writing, to the PWDPM within ten (10) business days of receiving the decision. The appeal shall be decided by the PWDPM. A response to the appeal will be issued to the individual within ten (10) business days.

If an individual wishes to file an EEO complaint, or pursue Merit Systems Protection Board (MSPB) and union grievance procedures if applicable, s/he must take the following steps: · · · · For an EEO complaint pursuant to 29 C.F.R. § 1614, contact an EEO counselor within 45 days from the date of this notice of denial of reasonable accommodation; or For a collective bargaining claim, file a written grievance in accordance with the provisions of the Collective Bargaining Agreement, or Administrative grievance procedure as appropriate; or Initiate an appeal to the Merit Systems Protection Board within 30 days of an appealable adverse action as defined in 5 C.F.R. § 1201.3; or Utilize the Alternative Dispute Resolution (ADR) process.
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U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-6081 (Rev. 03-06)