403.7E3 - RESCINDED (Feb 2025) Religious Accommodation Request Form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

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Office Use

This request has been:

______________________________  ________________________________
Approved                                                                    Denied

_______________________________________________________________ 
Administrator                                                                Date