403.7E3 - 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