403.7E3 - Religious Accommodation Request Form

RELIGIOUS ACCOMMODATION REQUEST FORM

Date:

 

Employee Name:

 

Email Address:

 

Position/Job Title:

 

Employee Telephone Number:

 

Employment Location:

 

 

(1)     Please identify the policy requirement or practice that conflicts with your sincerely held religious observance, practice or belief:

 

 

(2)     Please describe the nature of your sincerely held religious beliefs or religious practice or observance that conflict with the policy or practice you have identified above:

 

 

(3)     What are you requesting an accommodation from?

 

Item

Yes/No

Vaccination for COVID-19

 

Testing for COVID-19

 

Use of Face Coverings

 

 

 

  

___________________________________              ________________________________

Employee Signature                                                                Date

 

 

Office Use

 

This request has been: 

______________________________                        ________________________________

Approved                                                                                Denied

 

__________________________________                ______________________________

Administrator                                                                          Date