FEMA Reasonable Accommodation Medical Request Form

OMB Control No: 1660-0171	ICR Reference No: 202601-1660-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: DHS/FEMA	Agency Tracking No: 1660-NW179
Title: FEMA Reasonable Accommodation Medical Request Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/02/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/13/2026
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2029	36 Months From Approved
Responses	232	0	0
Time Burden (Hours)	116	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: FEMA’s new form supports a fair, efficient, and consistent process for evaluating employee requests for reasonable accommodations. It ensures that medical information is collected by license health care providers, helping the agency make informed decisions. FEMA is streamlining the process by ensuring that all necessary and relevant information is consistently captured. By providing a clear and uniform structure, it enhances efficiency for employees and licensed health care providers, while reducing the potential for delays caused by incomplete or insufficient submissions of medical documentation.

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Authorizing Statute(s): US Code: 29 USC 701 Name of Law: Rehabilitation Act of 1973    EO: EO 13163 Name/Subject of EO: Increasing the Opportunity for Individuals With Disabilities To Be Employed in the Federal Governmen    US Code: 5 USC 552a Name of Law: Privacy Act of 1974

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 39411	08/15/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 6236	02/11/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name FEMA Reasonable Accommodation Medical Request Form (FEMA Form FF-256-FY-25-100) FEMA Form FF-256-FY-25-100 FEMA Reasonable Accommodation Medical Request Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	232	0	0	232	0	0
Annual Time Burden (Hours)	116	0	0	116	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $469,728

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Kevin Crosby 202 550-6482 [email protected]

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(i) Why the information is being collected;
			(ii) Use of information;
			(iii) Burden estimate;
			(iv) Nature of response (voluntary, required for a benefit, or mandatory);
			(v) Nature and extent of confidentiality; and
			(vi) Need to display currently valid OMB control number;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date: 02/13/2026

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