Form PD407-015 "Reasonable Accommodation Request for Job Applicants" - New York City

What Is Form PD407-015?

This is a legal form that was released by the New York City Police Department - a government authority operating within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the New York City Police Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PD407-015 by clicking the link below or browse more documents and templates provided by the New York City Police Department.

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Download Form PD407-015 "Reasonable Accommodation Request for Job Applicants" - New York City

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FOR EEOD USE ONLY
REASONABLE ACCOMMODATION REQUEST
RA No. _________________
FOR JOB APPLICANTS
Date Request
PD 407-015 (Rev. 01-19)
Received: _______________
CONFIDENTIAL
The New York City Police Department will make reasonable accommodations to qualifi ed job
applicants with disabilities, religious beliefs/practices/observances, those who are pregnant and/
or recovering from childbirth or a related medical condition, and victims of domestic violence,
sex offenses, or stalking unless providing such accommodations would impose undue hardship.
SECTION I – This section to be completed by job applicant. Upon completion of this section,
submit this form to NYPD hiring personnel responsible for conducting the employment application
process.
Name: _____________________________________________________________________
Address: ___________________________________________________________________
Home Phone No.: ______________________ Cell Phone No.:________________________
Email: _____________________________________________________________________
Position Sought: _____________________________ Date Request Received: ___________
Department or Unit (if known): ___________________________________________________
Location of Position (if known): __________________________________________________
Parts of the employment process for which an accommodation is requested:
Job Application
Job Vacancy Notice Number (if known): _____________________
Interview
Interview Date: _______________
Exam
Examination Date: ____________ Exam No. ________________
At Work
Other (please specify): _________________________________________________
NYPD Contact Person (if known): ________________________________________________
Phone Number: _____________________________________________________________
Basis of reasonable accommodation request:
Disability
Religious
Describe your religious belief / practice / observances and identify the accommodation(s)
you request:
Status as Victim of Domestic Violence, Sex Offenses or Stalking
Pregnancy, Childbirth, or a Related Medical Condition
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
FOR EEOD USE ONLY
REASONABLE ACCOMMODATION REQUEST
RA No. _________________
FOR JOB APPLICANTS
Date Request
PD 407-015 (Rev. 01-19)
Received: _______________
CONFIDENTIAL
The New York City Police Department will make reasonable accommodations to qualifi ed job
applicants with disabilities, religious beliefs/practices/observances, those who are pregnant and/
or recovering from childbirth or a related medical condition, and victims of domestic violence,
sex offenses, or stalking unless providing such accommodations would impose undue hardship.
SECTION I – This section to be completed by job applicant. Upon completion of this section,
submit this form to NYPD hiring personnel responsible for conducting the employment application
process.
Name: _____________________________________________________________________
Address: ___________________________________________________________________
Home Phone No.: ______________________ Cell Phone No.:________________________
Email: _____________________________________________________________________
Position Sought: _____________________________ Date Request Received: ___________
Department or Unit (if known): ___________________________________________________
Location of Position (if known): __________________________________________________
Parts of the employment process for which an accommodation is requested:
Job Application
Job Vacancy Notice Number (if known): _____________________
Interview
Interview Date: _______________
Exam
Examination Date: ____________ Exam No. ________________
At Work
Other (please specify): _________________________________________________
NYPD Contact Person (if known): ________________________________________________
Phone Number: _____________________________________________________________
Basis of reasonable accommodation request:
Disability
Religious
Describe your religious belief / practice / observances and identify the accommodation(s)
you request:
Status as Victim of Domestic Violence, Sex Offenses or Stalking
Pregnancy, Childbirth, or a Related Medical Condition
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
Identify the situation which requires accommodation:
Please be specifi c. Attach additional sheets of paper, if necessary
Is the condition for which you are requesting an accommodation:
Permanent
Temporary
Unknown
If temporary, anticipated date accommodation(s) no longer needed: _____________________
Describe the nature of reasonable accommodation requested and how the accommodation
will assist you to perform the essential functions of the position held or desired, or to enjoy the
benefi ts and privileges of employment. Please be specifi c. (Attach additional sheets and present
supporting documentation as appropriate).
If equipment is requested, please specify brand, model number, and vendor, if known.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
For Reasonable Accommodations based on Disability, you may be required to provide
verifi cation by a health professional or a disability service provider (e.g., ACCESS-VR,
NYS Commission for the Blind and Visually Impaired, etc.)
This CONFIDENTIAL documentation must be provided to the
Equal Employment Opportunity Division
Documentation must:
Be written on offi cial letterhead of the qualifi ed health professional or health
professional’s organization.
Identify the health professional’s credentials (e.g., M.D., D.O., etc.).
Be dated and signed by the health professional.
Describe the severity of the disability and its limitations, in detail, as they currently
exist and only in relationship to the job.
State whether the duration of disability is permanent or temporary or unknown.
If temporary, specify the date the disability is expected to no longer require
accommodation.
Indicate the extent to which the accommodation will permit you to perform the
essential functions of the job or to enjoy the benefi ts and privileges of employment.
I certify that I have read and understood the information provided in this request, and that
it is true to the best of my knowledge, information, and belief.
Applicant’s Signature: __________________________________ Date: _________________
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
CONFIDENTIAL
SECTION II – Must be completed by the NYPD hiring personnel responsible for interviewing or
supervising the employment application process:
Hiring Member’s Rank / Title and Name: ___________________________________________
Command: _______________________________________ Tax No.: ___________________
Supervisor Telephone No. ______________________________________________________
Cell Phone No. ______________________________________________________________
Best E-mail Address: __________________________________________________________
Date Request Received: _______________________________________________________
SECTION III – NYC Police Department hiring personnel must promptly telephone the Deputy
Commissioner, Offi ce of Equity and Inclusion, Equal Employment Opportunity Division (EEOD)
at (646) 610-5330 to inform the EEOD of the applicant’s name, the accommodation requested,
and other pertinent information.
Name of EEOD member notifi ed: ________________________________________________
Hiring Personnel’s Signature: _______________________________ Date: _______________
*****************************************************************************************
After completing the above sections, NYPD hiring personnel must:
 Provide a copy of this form to the applicant.
 Fax or email a copy to the Reasonable Accommodation Unit at (646) 610-5898 or
ReasonableAccommodation.request@nypd.org.
 Ensure that confi dentiality is maintained and take necessary action as required by
Administrative Guide procedure 320-47.
 Forward original request and any supporting documentation to the:
DEPUTY COMMISSIONER, OFFICE OF EQUITY AND INCLUSION
EQUAL EMPLOYMENT OPPORTUNITY DIVISION
ONE POLICE PLAZA, ROOM 1204
NEW YORK, NEW YORK 10038
ATTN: REASONABLE ACCOMMODATION UNIT
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
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