United States Department of Agriculture

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Sun, 12/22/2019 - 9:20am -- Anonymous
Type of AT Request: 
USDA Agency: 
What category best describes the disabling conditions or functional limitations related to the employee's tasks?: 
Blind (e.g. Legally blind)
Low Vision (e.g., difficulty seeing characters on a screen or printed page)
Cognitive (e.g., difficulty focusing on printed or spoken information, expressing information, remembering things)
Communication (e.g., difficulty communicating)
Deaf / Hard of Hearing (all degrees of hearing loss)
Dexterity (e.g., wrist, hand, neck, back or leg discomfort, paralysis, fine motor skill problems)
What are his/her diagnosed condition/limitation(s)?: 
Requested Accommodation: 
Has he/she used assistive technology before?: 
What are his/her job function(s)?: 
USDA Office Shipping Addresses Only: 
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Employee Contact Information: 
Employee Contact Information
Phone Number: 
Reasonable Accommodation Contact: 

Reasonable Accommodation Contact

Phone Number: 
Supervisor Contact Information: 

Supervisor Contact Information

Phone Number: 
Does the Reasonable Accommodation contact have medical documentation on file?: 
Limitations Text: 

Give us a description of his/her specific impairment(s) or functional limitations. Is there a medical diagnosis from a doctor? Is this a new condition or something that he/she been dealing with long-term?

Requested Accommodation text: 

If you are unsure of your technology and training needs, please contact the TARGET Center to request an AT Needs Assessment.

Assistive Technology Text: 

If he/she has used or is currently using assistive technology, let us know. We may be able to suggest something else that works with or complements what he/she is using.

Job functinos text: 

Provide a description of normal tasks that the Employee needs to perform and complete at work that are hindered by his/her limitations. You may want to describe the current work environment, interactions with co-workers and/or supervisors or any other details that you feel could be helpful.