Information on requestor
Name, occupational series and grade level, office (including correspondence symbol), telephone number, fax number and email address.
GSA3676
Confirmation of Reasonable Accommodation Request (Disability)
- Agency
- GSA
- Revision
- Rev. 8/2024
- Fillable fields
- 15
- Pages
- 2
- Official source
- GSA form page
- Checked
- October 20, 2026
GSA Form 3676: Confirmation of Reasonable Accommodation Request (Disability)
GSA Form 3676, Confirmation of Reasonable Accommodation Request (Disability), is a two-page GSA form. The footer reads GENERAL SERVICES ADMINISTRATION and GSA 3676 (REV. 8/2024), and GSA hosts it in its forms library. GSA's page lists HRM 2300.1 as the authority or regulation.
The front records information on the requestor, then the request: the date, the need (application process, performing job functions or accessing the work environment, accessing a benefit or privilege, or personal assistance services), the type of accommodation and the reasons. The requestor signs and dates it. The Privacy Act statement on the back says requesting a reasonable accommodation is a voluntary process and that access to the information is limited to individuals with a need to know.
You can fill it out free in your browser on this page and download the result without an account.
What's on GSA Form 3676
Request date and need
The date, and one need checked: application process, performing job functions or accessing work environment, accessing a benefit or privilege (e.g., attending a training program or social event), or personal assistance services.
Type(s)
The kind of accommodation, with the examples adaptive equipment, staff assistant and removal of architectural barrier.
Reason(s)
The reasons for the request. The form says if the accommodation is time sensitive, please explain.
Signature and date
Signature of requestor and date at the bottom of the front page.
Privacy Act statement
On the back: confidentiality, statutory authority, purpose and use, routine use, and the consequence for not supplying the requested information.
How to complete GSA Form 3676
- 1
Read the Privacy Act statement
The front says to see the Privacy Act statement on the reverse, which covers who may see the information and why it is collected.
- 2
Enter your details
Fill in name, occupational series and grade level, office with correspondence symbol, telephone, fax and email address.
- 3
Date it and check one need
Enter the date of the request and check one need box. The form says Check one.
- 4
Describe the type and reasons
List the type or types of accommodation and the reasons. If it is time sensitive, the form asks you to explain.
- 5
Sign and date
Sign on the signature of requestor line and enter the date.
The form prints no separate instructions. These steps follow its boxes in order.
Why fill Form GSA3676 on indox
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- Works on a phone, tablet or computer
Where it goes and what the form says
Where it goes
The PDF prints no address or recipient. GSA's page lists HRM 2300.1 as the authority or regulation.
Statutory authority
The form lists 29 U.S.C. § 791; 42 U.S.C. § 12101; 42 U.S.C. § 2000e-16; 29 U.S.C. § 2601; 40 U.S.C. § 3173; and E.O. 13164, E.O. 13548, E.O. 14042 and E.O. 14043.
Purpose and use
The form says the information is used to facilitate the reasonable accommodation process for individuals with disabilities or religious beliefs provided in support of a request for accommodation or exemption from a requirement or penalty.
Confidentiality
Access is limited to individuals with a need to know. The routine uses listed in GSA/HRO-1 apply.
Not supplying information
The form says if an employee or applicant does not provide the necessary information, including medical or religious information, a decision-maker may deny the request.
Related forms
Who fills out GSA Form 3676?
The form has one signature line, for the requestor. The Privacy Act statement names the others involved.
Official sources and the blank
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Questions about Form GSA3676
Who issues GSA Form 3676?
The footer reads GENERAL SERVICES ADMINISTRATION and GSA 3676 (REV. 8/2024). GSA hosts the form in its forms library, and its page lists HRM 2300.1 as the authority or regulation.
Is requesting an accommodation voluntary?
The Privacy Act statement says requesting a reasonable accommodation is a voluntary process.
What needs can be checked on the form?
Four: application process; performing job functions or accessing work environment; accessing a benefit or privilege, such as attending a training program or social event; and personal assistance services. The form says to check one.
What kinds of accommodation does the form give as examples?
The Type(s) box gives adaptive equipment, staff assistant and removal of architectural barrier as examples.
Who can see the information?
The form says access is limited to individuals with a need to know, including those in the routine uses of the System of Records Notice GSA-HRO-1, and that in some limited cases GSA works with external partners.
What if I leave information out?
The form says if an employee or applicant does not provide the necessary information, including medical or religious information, a decision-maker may deny the reasonable accommodation request.