Religious Accommodation Request Form

Part 1: To be completed by employee

Name: _______________________ Department: ___________________

Date of request: _________________________________

Immediate supervisor: __________________________________

Requested accommodation (job change, schedule change, dress/appearance code exception, vaccination exemption, etc.):

_________________________________________________________________

_________________________________________________________________

Length of time the accommodation is needed: ____________________________

Describe the religious belief or practice that necessitates this request for accommodation:

________________________________________________________________

________________________________________________________________

________________________________________________________________

Describe any alternate accommodations that might address your needs:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

I have read and understand [Company Name]'s policy on religious accommodation. My religious beliefs and practices, which result in this request for a religious accommodation, are sincerely held. I understand that the accommodation requested above may not be granted but that the company will attempt to provide a reasonable accommodation that does not create an undue hardship on the company. I understand that [Company Name] may need to obtain supporting documentation regarding my religious practice and beliefs to further evaluate my request for a religious accommodation.

Employee signature: _____________________________ Date: ___________________

Part 2: To be completed by the employee's immediate supervisor

Describe the requested accommodation:

________________________________________________________________

________________________________________________________________

Evaluation of impact (if any): _________________________________________

_________________________________________________________________

_________________________________________________________________

Approved: _____________ Denied: _______________

If the requested accommodation is denied, what are some alternative accommodations (list in order of preference):

1. __________________________________________________________

2. __________________________________________________________

3. __________________________________________________________

Date discussed with employee:  _________________________________________

Final accommodation agreed upon: _________________________________________

If no agreement on an accommodation, provide an explanation:

_____________________________________________________________________

_____________________________________________________________________

Immediate supervisor: _______________________________   Date: _____________

Manager of immediate supervisor: _______________________ Date: _____________

Human resources director: _____________________________ Date: _____________