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: _____________
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