Form HUD-11601 "Reasonable Accommodation Information Reporting Form"

What Is Form HUD-11601?

This is a legal form that was released by the U.S. Department of Housing and Urban Development and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest available edition released by the U.S. Department of Housing and Urban Development;
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Download a fillable version of Form HUD-11601 by clicking the link below or browse more documents and templates provided by the U.S. Department of Housing and Urban Development.

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U.S. Department of Housing and Urban Development
Office of Administration
REASONABLE ACCOMMODATION INFORMATION
REPORTING FORM
Enter the following information about the employee or applicant who requested the reasonable
accommodation:
Requester’s Name:
Office & Location:
Control Number Assigned:
RA-
1
Reasonable Accommodation: (Check one)
.
Approved
Denied
f denied, attach copy of the Denial of Reasonable
(i
Accommodation Request Form HUD-11600)
.)
2
Date Reasonable Accommodation requested:
.
(Enter Date of Receipt)
Name and Title of person who received initial request:
3
Date Reasonable Accommodation request referred to Decision Maker (
i.e., Supervisor, Disability
.
Program Manager, Principal Organization Head):
(Enter Date of Receipt)
Name and Title of Decision Maker:
4
Date Reasonable Accommodation approved or denied:
.
(Enter Date of Decision)
5
Date Reasonable Accommodation provided:
.
(Enter, if different from date approved)
6. If time frames outlined in the Reasonable Accommodation Procedures were not met, please explain
Why:
7. Current position or, if an applicant, desired position of the individual requesting Reasonable
Accommodation (
):
including position title, series, grade level, and office
Form HUD-11601
U.S. Department of Housing and Urban Development
Office of Administration
REASONABLE ACCOMMODATION INFORMATION
REPORTING FORM
Enter the following information about the employee or applicant who requested the reasonable
accommodation:
Requester’s Name:
Office & Location:
Control Number Assigned:
RA-
1
Reasonable Accommodation: (Check one)
.
Approved
Denied
f denied, attach copy of the Denial of Reasonable
(i
Accommodation Request Form HUD-11600)
.)
2
Date Reasonable Accommodation requested:
.
(Enter Date of Receipt)
Name and Title of person who received initial request:
3
Date Reasonable Accommodation request referred to Decision Maker (
i.e., Supervisor, Disability
.
Program Manager, Principal Organization Head):
(Enter Date of Receipt)
Name and Title of Decision Maker:
4
Date Reasonable Accommodation approved or denied:
.
(Enter Date of Decision)
5
Date Reasonable Accommodation provided:
.
(Enter, if different from date approved)
6. If time frames outlined in the Reasonable Accommodation Procedures were not met, please explain
Why:
7. Current position or, if an applicant, desired position of the individual requesting Reasonable
Accommodation (
):
including position title, series, grade level, and office
Form HUD-11601
U.S. Department of Housing and Urban Development
Office of Administration
REASONABLE ACCOMMODATION INFORMATION
REPORTING FORM,
Page 2
8.
Reasonable Accommodation needed for: (Check one)
Application Process
Performing Job Functions or Accessing the Work Environment
Accessing a Benefit or Privilege of Employment
(e.g., attending a training program or social
event):
9
Type(s) of Reasonable Accommodation provided
(e.g., adaptive equipment, staff assistant, removal of
.
Architectural barrier):
10
Type(s) of reasonable accommodation provided
(if different from what was requested):
.
11
Was medical information required to process this request? If yes, explain why.
.
12
Sources of technical assistance, if any, consulted in trying to identify possible Reasonable
.
Accommodations
(e.g., Job Accommodation Network, disability organization, Disability Program
Manager):
13
Comments:
.
Name and Title of person completing this form
Date
Room Number
Telephone Number/Extension
Attach copies of all documents obtained or developed in processing this request.
Form HUD-11601
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