National Aeronautics and Space Administration

Request for Reasonable Accommodation

1. REQUESTER'S NAME

2. NASA OFFICIAL RECEIVING REQUEST

3. DATE OF REQUEST

4. REQUEST NUMBER [NOTE: EMPLOYEES, PLEASE LEAVE THIS BLANK]

5. REQUESTER'S TELEPHONE NUMBER

6. ACCOMMODATION(S) REQUESTED (Be as specific as possible, e.g., adaptive equipment, reader, interpreter)

7. REASON(S) FOR REQUEST

8. IF ACCOMMODATION IS TIME-SENSITIVE, PLEASE EXPLAIN

NASA FORM 1699 NOV 01