Request for Accommodation in Communication Method

Other Accommodation Information Entry Screen

Other Accommodation Information Entry Screen (concluded)

Verification/Summary Screen

Confirmation Screen

Other Accommod
dation Histo
ory Summary Screen
n

Other Accommodation History Summary Screen (Other Accommodation Requests After
May 2011 Release)

Intranet (CSR) Screens
S
(Query Mode)
Client Authenticattion Screen

Special Notice Option Selection Screen

Other Accommod
dation Histo
ory Summary Screen
n

Other Accommodation History Summary Screen (Other Accommodation
Requests After May 2011 Release)

SSA will insert the following revised Privacy Act and PRA Statements into the Intranet Screen
Shots upon OMB’s Approval:
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, and the Rehabilitation Act of 1973, as
amended, authorize us to collect the information requested on this form. Social Security will
only use the information you provide to verify your identity and to process your request for a
notice accommodation. The Privacy Act (5 U.S.C. & 552a(b)) permits us to disclose the
information you provide on this form in accordance with approved routine uses. Giving us this
information is voluntary; however, failing to complete the required fields could prevent us from
processing your request. Additional information regarding this form, routine uses of
information, and other Social Security programs, is available on our internet website,
www.socialsecurity.gov, or at your local Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do
not need to answer these questions unless we display a valid Office of Management and Budget
(OMB) control number. We estimate that it will take about 20 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-0001